Adult Outcome Form

IMPORTANT-PLEASE READ THIS FIRST.

This form has 18 statements about how you have been OVER THE LAST WEEK. Please read each statement and think how often you felt that way last week. Then click in the box which is closest to this.

Site ID


Stage Completed

F= First Therapy Session, D= During Therapy, L= Last Therapy Session

Client ID

Session Number


(First Therapy Session=001)

Date Completed

Over the last week

1. I have felt tense, anxious or nervous

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

2. I have felt OK about myself

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

3. Unwanted images or memories have been distressing me

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

4. I have achieved the things I wanted to

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

5. I have felt humiliated or shamed by other people

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

6. I have felt like crying

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

7. I have felt warmth or affection for someone

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

8. My problems have been impossible to put to one side

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

9. I have been physically violent to others

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

10. I have felt despairing or hopeless

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

11. I have felt criticized by other people

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

12. I have felt able to cope when things go wrong

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

13. I have felt unhappy

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

14. I have been irritable when with other people

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

15. I have felt overwhelmed by my problems

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

16. I have felt panic or terror

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

17. I have felt optimistic about my future

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time

18. I have hurt myself physically or taken dangerous risks with my health

0 Not at all1 Only Occasionally2 Sometimes3 Often4 Most or all the time