Proposed Adult Questionnaire Items

Jeb Brown, PhD

These items have been drafted using the same format and anchors as items contained in the Peabody battery for children and adolescents. The items on the following pages are organization into various domains, with room to add additional items.

Some of the items are from the Peabody battery, but I have added many new items drafted to be suitable for adults. To my knowledge, none of the items I’ve added are copyrighted in their present form. However, as is the case with all questionnaires designed for use with individuals seeking mental health treatment, there is a large degree of commonality in the content of the items enquiring about the symptoms, problems and concerns most frequently expressed by individuals seeking mental health services.

I’ve have organized the items into content/purpose domains: global distress, risk identification (suicide, substance abuse), therapeutic alliance, social support, and stage of change.

Feel free to make additions and suggestions.

Adult symptoms, interpersonal & work/school productivity items; global distress factor

In the past week or two, how often did you / Rarely / Hardly Ever / Some-times / Often / Very often
1 / …feel unhappy or sad?
2 / …have little or no energy?
3 / …have a hard time controlling your temper?
4 / …worry about a lot of things?
5 / …have a hard time getting along with family or friends?
6 / …feel worthless?
7 / …have a hard time having fun?
8 / …sleep more than you usually do?
9 / …have a hard time paying attention?
10 / …have a hard time sitting still?
11 / …have trouble sleeping.
12 / …feel tense or nervous?
13 / …cry easily?
14 / …get into arguments with friends or family?
15 / …feel lonely?
16 / …have a headache or pain in your body?
17 / …worry about medical problems?
18 / …feel irritated
19 / …worry about family problems.
20 / …feel hopeless about the future.
21 / …feel no interest in things.
22 / …feel too nervous to leave your house.
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Risk detection items: suicide, assault behavior, and substance abuse

In the past week or two, how often did you / Rarely / Hardly Ever / Some-times / Often / Very often
1 / …have thoughts of suicide.
2 / …feel like you wanted to hurt someone.
2 / …have someone express concerns about your alcohol or drug use
3 / …think your drinking or drug use was a problem.
4 / …have trouble at work or elsewhere because of your drinking or drug use?

Therapeutic alliance items:

In the past week or two, how often did you / Rarely / Hardly Ever / Some-times / Often / Very often
1 / …feel like your therapist/doctor liked you?
2 / …feel like you and your therapist/doctor agreed on what treatment would be best?
3 / …feel like your therapist/doctor respected you?
4 / …talk about the things that were important to you in therapy.
5 / …feel like your therapist/doctor understood you?
6 / …feel like your therapist/doctor wanted you feedback about how treatment was going?
7 / …feel like your therapist/doctor was interested in your thoughts and feelings?
8 / …feel like you therapist/doctor was trust worth?
9 / …feel that your therapist/doctor was honest and sincere?
10 / …feel hopeful after a therapy session?
11 / …believe that the therapy was helpful?
12 / …believe that the treatment you are receiving is right for you?

Social support items

In the past week or two, how often did you / Rarely / Hardly Ever / Some-times / Often / Very often
1 / …feel that you had no one you could turn to for help?
2 / …feel emotionally supported by family and/or friends?
3 / …enjoy yourself with family or friends?
4 / …feel that the most important people in your life were supportive?
5 / ...have people in your life that care what happens to you?
6 / …get invited to go out with other people?
7 / …get to talk to someone you trust and personal matters that are important to you?

Stage of change:

In the past week or two, how often did you / Rarely / Hardly Ever / Some-times / Often / Very often
1 / …believe that there are things that you can do to help yourself feel better?
2 / …use something you learned in therapy to feel better or solve a problem?
3 / …have confidence that you will be able to handle problems in the future?
4 / …feel that you did not need therapy?
5 / …believe that treatment would not be helpful for you?
6 / …think it would be a good idea to make changes in your life?
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