Session 4 - Doncaster and Bassetlaw Teaching Hospitals

BMS - Full

Brief Mood Survey

Name
First Last
Date
MM slash DD slash YYYY
Please complete the following surveys BEFORE and AFTER the session. Please only complete the last part of the survey AFTER the session. Thank you!
Pre or post session answers?
Brief Mood Survey
Instructions. Use the selections to indicate how you're feeling right now. Please answer all the items.
How depressed do you feel right now?
Sad or down in the dumps*
Not at all Somewhat Moderately A lot Extremely
Discouraged or hopeless*
Not at all Somewhat Moderately A lot Extremely
Low self-esteem, inferiority, worthlessness*
Not at all Somewhat Moderately A lot Extremely
Loss of motivation to do things*
Not at all Somewhat Moderately A lot Extremely
Loss of pleasure or satisfaction in life*
Not at all Somewhat Moderately A lot Extremely
Suicidal urges:
Do you sometimes
Feel like you’d be better off dead?*
Not at all Somewhat Moderately A lot Extremely
Have suicidal thoughts or fantasies?*
Not at all Somewhat Moderately A lot Extremely
Have urges or plans to end your life?*
Not at all Somewhat Moderately A lot Extremely
How anxious do you feel right now?
Anxious*
Not at all Somewhat Moderately A lot Extremely
Frightened*
Not at all Somewhat Moderately A lot Extremely
Worrying about things*
Not at all Somewhat Moderately A lot Extremely
Tense or on edge*
Not at all Somewhat Moderately A lot Extremely
Nervous*
Not at all Somewhat Moderately A lot Extremely
How angry do you feel right now?
Frustrated*
Not at all Somewhat Moderately A lot Extremely
Annoyed*
Not at all Somewhat Moderately A lot Extremely
Resentful*
Not at all Somewhat Moderately A lot Extremely
Angry*
Not at all Somewhat Moderately A lot Extremely
Irritated*
Not at all Somewhat Moderately A lot Extremely
Happiness
Instructions. Use the selections to indicate how you're feeling right now. Please answer all the items.
Happy and joyful*
Not at all Somewhat Moderately A lot Extremely
Hopeful and optimistic*
Not at all Somewhat Moderately A lot Extremely
Worthwhile, high self-esteem*
Not at all Somewhat Moderately A lot Extremely
Motivated, productive*
Not at all Somewhat Moderately A lot Extremely
Pleasure and satisfaction in life*
Not at all Somewhat Moderately A lot Extremely
Relationship Satisfaction
Put the name of an important relationship in your life:
Use the selections to indicate how you feel about this relationship. Please answer all 5 items.
Communication and openness*
Very Dissatisfied Moderately Dissatisfied Somewhat Dissatisfied Neutral Somewhat Satisfied Moderately Satisfied Very Satisfied
Resolving conflicts*
Very Dissatisfied Moderately Dissatisfied Somewhat Dissatisfied Neutral Somewhat Satisfied Moderately Satisfied Very Satisfied
Degree of affection and caring*
Very Dissatisfied Moderately Dissatisfied Somewhat Dissatisfied Neutral Somewhat Satisfied Moderately Satisfied Very Satisfied
Intimacy and closeness*
Very Dissatisfied Moderately Dissatisfied Somewhat Dissatisfied Neutral Somewhat Satisfied Moderately Satisfied Very Satisfied
Overall satisfaction*
Very Dissatisfied Moderately Dissatisfied Somewhat Dissatisfied Neutral Somewhat Satisfied Moderately Satisfied Very Satisfied
How much psychotherapy homework have you done since your last session?*
None A little A moderate amount A lot
Please fill this part out AFTER the session
Skip straight to the submit button at the end, if it is a pre-session form. Thank you!
Evaluation of Therapy Session
Instructions. Use selections to indicate how you felt about your most recent therapy session. Please answer all the items.
Therapeutic Empathy
My therapist seemed warm, supportive, and concerned.
Not at all true Somewhat true Moderately true Very true Completely true
My therapist seemed trustworthy.
Not at all true Somewhat true Moderately true Very true Completely true
My therapist treated me with respect.
Not at all true Somewhat true Moderately true Very true Completely true
My therapist did a good job of listening.
Not at all true Somewhat true Moderately true Very true Completely true
My therapist understood how I felt inside.
Not at all true Somewhat true Moderately true Very true Completely true
Helpfulness of the Session
I was able to express my feelings during the session.
Not at all true Somewhat true Moderately true Very true Completely true
I talked about the problems that are bothering me.
Not at all true Somewhat true Moderately true Very true Completely true
The techniques we used were helpful.
Not at all true Somewhat true Moderately true Very true Completely true
The approach my therapist used made sense.
Not at all true Somewhat true Moderately true Very true Completely true
I learned some new ways to deal with my problems.
Not at all true Somewhat true Moderately true Very true Completely true
Satisfaction with Today's Session
I believe the session was helpful to me.
Not at all true Somewhat true Moderately true Very true Completely true
Overall, I was satisfied with today's session.
Not at all true Somewhat true Moderately true Very true Completely true
Your Commitment
I plan to do therapy homework before the next session.
Not at all true Somewhat true Moderately true Very true Completely true
I intend to use what I learned in today's session.
Not at all true Somewhat true Moderately true Very true Completely true
Negative Feelings During the Session
At times, my therapist didn't seem to understand how I felt.
Not at all true Somewhat true Moderately true Very true Completely true
At times, I felt uncomfortable during the session.
Not at all true Somewhat true Moderately true Very true Completely true
I didn't always agree with my therapist.
Not at all true Somewhat true Moderately true Very true Completely true
Difficulties with the Questions
It was hard to answer some of these questions honestly.
Not at all true Somewhat true Moderately true Very true Completely true
Sometimes my answers didn't show how I really felt inside.
Not at all true Somewhat true Moderately true Very true Completely true
It would be too upsetting for me to criticize my therapist.
Not at all true Somewhat true Moderately true Very true Completely true
What did you like the least about the session?
What did you like the best about the session?
Electronic Form. *Copyright © 2001 by David D. Burns, M.D. Revised, 2004, 2020. This tool is only to be used by mental health professionals in the treatment of their patients in HIPAA compliant teletherapy applications. Do NOT send out blank forms via regular mail or email. This tool may not be published on the internet or distributed to others, including colleagues. Please see your electronic license agreement

Session 4 resources: https://www.dbth.nhs.uk/tier-3-weight-management-patient-portal/cbt/unhelpful-thinking-habits/session-4-resources/session-4/

Content out of date? Information wrong or not clear enough? Report this page.

BMS - Full

Brief Mood Survey

Suicidal urges:

How anxious do you feel right now?

How angry do you feel right now?

Happiness

Relationship Satisfaction

Please fill this part out AFTER the session

Evaluation of Therapy Session

Therapeutic Empathy

Helpfulness of the Session

Satisfaction with Today's Session

Your Commitment

Negative Feelings During the Session

Difficulties with the Questions