STUDY #1

ID #_______Date __________ Pre-tx

HV1

S8

S12

S16

S20

Post-tx

3MO

6MO

1Yr

Current Symptoms Self-Report Form Rater: Therapist

Clutter Image Rating

Week of:

Instructions: Please check the response next to each item that best describes your behavior during the past week.

Using the 3 series of pictures (CIR: Living Room, CIR: Kitchen, and CIR: Bedroom), please select the picture that best represents the amount of clutter for each of the rooms of your home. Put the number on the line below. Never or Rarely toSometimes Often Very Often Please pick the picture that is closest being accurate, even if it is not exactly right. If your home does not have one of the rooms listed, just put NA for not applicable on that line.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Fail to give close attention to details or make careless Number of closest corresponding picture (1-9) mistakes Room in my work Fidget with handsRoom or feet or squirm in _______ seat Living Have diculty sustaining my attention in tasks or Kitchen _______ fun activities Leave myBedroom seat in situations is #1 in which seating _______ expected Dont listen when spoken to directly

Bedroom #2

_______

Also, please rate other rooms in your house that are affected by clutter on the lines below. Feel restless Use the CIR: Living Room pictures to make these ratings.
Dont follow through on instructions and fail to nish work Dining room _______ Have diculty engaging in leisure activities or doing Hallway _______ fun things quietly

Garage _______ Have di culty organizing tasks and activities

Feel on the go or driven by a motor Basement _______ Avoid, dislike, or am reluctant to engage in work that Attic mental eort _______ requires sustained Talk excessively Car

_______ _______ Please specify: __________________________

Lose things necessary for tasks or activities

Other

Blurt out answers before questions have been completed Am easily distracted Have diculty awaiting turn Am forgetful in daily activities Interrupt or intrude on others

From R. A. Barkley & K. R. Murphy (1998), Attention-Decit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press. Reprinted with permission.Mastery

Treatments That Work Compulsive Hoarding and Acquiring

TM

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