USE THE RATING SCALE BELOW: 0 = NEVER 1 = SELDOM
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- Lucas Neal Doyle
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1 DBT Client History Survey So that we may most clearly understand your situation and align you with the most appropriate treatment, please answer the questions below with all honesty in the present moment.how things actually are in reality rather than how you might wish them to be. For each item, choose the number below which is closest to your experience. USE THE RATING SCALE BELOW: 0 = NEVER 1 = SELDOM (once a year) 2 = OCCASSIONALLY (every few months) 3 = OFTEN (once a month) 4 = FREQUENTLY (every other week or so) 5 = REGULARLY (daily up to every other week) 1. I struggle to keep my emotions under control 2. I don t have any emotions 3. Other people say that I take things too personally or seriously 4. When I get angry or sad or worried or fearful, it is very intense. 5. When I get angry or sad or worried or fearful, it takes a long time for me to calm down to being myself again. 6. I feel like my emotions run my life. 7. If only my family, job, school, friends, spouse, etc. would change, my life would be better. 8. Feelings are bad and wrong. 9. I can t trust my feelings. 10. I think that my opinions and thoughts are usually wrong. 11. I can t do anything good enough. 12. I am not good enough, strong enough, attractive enough, etc. 13. Everything is my fault. 14. No matter how hard I try to make things better, something gets in my way. 15. My life is a series of crises. 16. Bad things keep happening. 17. I get into physically or emotionally/verbally abusive relationships. 18. When I lose something or someone, I should just get over it.
2 19. I should just face my fear. 20. I don t like to feel sad. 21. It s not okay to be angry. 22. I feel helpless. 23. I feel like things just keep happening around me. 24. I need someone else to help me solve my problems. 25. People think I have it all together and it doesn t feel that way. 26. People don t take me seriously when I ask for help. 27. Other people think I have a problem with: (choose any) drugs, alcohol, food, spending, gambling 28. I think I have a problem with: (choose any) drugs, alcohol, food, spending, gambling 29. I have had, in the past, a problem with: (choose any) drugs, alcohol, food, spending, gambling Please do your best to provide the following information in detail: LIFETIME SUICIDE ATTEMPTS Date of event Age REASON (for each event) METHOD MEDICAL TREATMENT REQUIRED (Dr, ER, etc) LIFETIME PYSCHIATRIC HOSPITALIZATIONS Dates Age FACILITY REASON
3 SELF-HARM EPISODES (without intent to die) Cutting Burning Poison Misuse of drugs/alcohol Restriction of food intake Binge eating Purging activities (incl. laxatives) Tattoos Piercings Intentional non-compliance with medical treatment (ie, not taking pain medications, not taking insulin, etc.) Hitting self Thought about hurting yourself without the intent to die? Thought about killing yourself? AGE 1 ST USED METHOD LAST TIME USED TOTAL EVENTS PAST YEAR TOTAL MEDICAL TREATMENT REQUIRED? If yes, explain NA Had an actual plan to kill yourself? Other: NA
4 VALUED LIFE AREAS 1 Not at all Somewhat Extremely For each life area below, place an X in the box which most closely represents the degree to which you value or consider that dimension of your life, even if your life is not actually the way you want it to be in that area right now. Family of Origin Marriage/Significant Others Children Friends/Social Relationships Education/Lifelong learning Career/Life work Hobbies and Interests, pets Sports/Physical Activities Spirituality Community Involvement Health Living Environment Financial Stability
5 What would you most like to accomplish in your life? What would you most like to accomplish in treatment? What are your concerns about entering DBT treatment? What are the most things you would like us to know about you?
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