Age range

Have you received mental health treatment before?

1. Repeated, disturbing, unwanted memories of the stressful experience

2. Repeated, disturbing dreams of the stressful experience

3. Suddenly feeling or acting as if the stressful experience were actually happening again (flashbacks)

4. Feeling very upset when something reminded you of the stressful experience

5. Having strong physical reactions when something reminded you (heart pounding, trouble breathing, sweating)

6. Avoiding memories, thoughts, or feelings related to the stressful experience

7. Avoiding external reminders of the stressful experience (people, places, conversations, activities, objects)

8. Trouble remembering important parts of the stressful experience

9. Having strong negative beliefs about yourself, other people, or the world

10. Blaming yourself or someone else for the stressful experience or what happened after it

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame

12. Loss of interest in activities that you used to enjoy

13. Feeling distant or cut off from other people

14. Trouble experiencing positive feelings (unable to feel happiness or love)

15. Irritable behaviour, angry outbursts, or acting aggressively

16. Taking too many risks or doing things that could cause you harm

17. Being 'superalert' or watchful or on guard

18. Feeling jumpy or easily startled

19. Having difficulty concentrating

20. Trouble falling or staying asleep

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading or watching television

8. Moving or speaking so slowly others could have noticed — or being so fidgety or restless you've been moving around a lot more than usual

9. Thoughts that you would be better off dead, or of hurting yourself in some way

1. Feeling nervous, anxious, or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it is hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen

1. Rate the current severity of your insomnia:

Difficulty falling asleep

Difficulty staying asleep

Waking up too early

2. How satisfied/dissatisfied are you with your current sleep pattern?

3. How noticeable to others is your sleep problem in terms of impairing your quality of life?

4. How worried/distressed are you about your current sleep problem?

5. To what extent does your sleep problem interfere with your daily functioning?

1. Feeling disconnected from yourself, like watching yourself from outside your body

2. Things around you feel unreal, dreamlike, or foggy

3. Finding yourself somewhere with no memory of how you got there

4. Feeling emotionally numb or completely cut off from your feelings

5. Spacing out or losing awareness of your surroundings for periods of time

Current support system

Are you currently in physical danger or an unsafe environment?

In the past month, have you had thoughts of ending your life or harming yourself?

How difficult have these problems made daily life, work, or relationships?

Are you using alcohol or drugs more than usual to cope?

While you were growing up, during your first 18 years of life:

1. In the past month, how often have you felt that your life is empty or meaningless because of your loss?

2. In the past month, how often has it been hard to accept the death?

3. In the past month, how often have you felt stunned, dazed, or shocked by the loss?

4. In the past month, how often do memories of your loved one interfere with your ability to do everyday things?

5. In the past month, how often have you felt bitter, angry, or that moving on from the loss is impossible?