Psychological Evaluation For First Time Clients

Reminders: Kindly print out these 17 sheets. Write your name on all sheets.
Make sure to
answer ALL items. Make sure there is ONLY ONE ANSWER per item. Please submit the
answered pages on your first consultation appointment.
PSYCHOLOGICAL EVALUATION
Date: October 26, 2020 Name: Karen Paula Manalo Suliguin Age / Sex: 32/ F
Listed below are 20 statements. Please read each one carefully and decide how much the
statement describes how you have been feeling during the past week. Check the appropriate
box for each statement.
A little of Some of Good part Most of

the time the time of the time the time
1. I feel down hearted and blue. /
2. Morning is when I feel the worst. /
3. I have crying spells or feel like it. /
4. I have trouble sleeping at night. /
5. I do not eat as I used to. /
6. I do not enjoy sex as I used to. /
7. I notice that I am losing weight. /
8. I have trouble with constipation. /
9. My heart beats faster than usual. /
10. I get tired for no reason. /
11. My mind is not as clear as it used to be. /
12. I find it difficult to do the things I used /

to.
13. I am restless and can’t keep still. /
14. I feel hopeless about the future. /

15. I am more irritable than usual. /
16. I find it difficult to make decisions. /
17. I feel that I am useless and unneeded. /
18. My life is empty. /
19. I feel that others would be better off if I /

were dead.
20. I do not enjoy the things I used to do. /
Listed below are 20 statements. Please read each one carefully and decide how much the
statement describes how you have been feeling during the past week. Check the appropriate
box for each statement.

1. I feel more nervous and anxious than /
usual.
2. I feel afraid for no reason at all. /
3. I get upset easily or feel panicky. /
4. I feel like I’m falling apart and going to /

pieces.
5. I feel that not all is well and that /

something bad will happen.
6. My arms and legs shake and tremble. /
7. I am bothered by headaches neck and /

back pain.
8. I feel weak and get tired easily. /

9. I feel restless and cannot sit still easily. /
10. I can feel my heart beating fast. /
11. I am bothered by dizzy spells. /
12. I have fainting spells or feel like it. /
13. I have difficulty breathing in and out /

easily.
14. I get numbness and tingling in my /

fingers and toes.
15. I am bothered by stomach aches or /

indigestion.
16. I have to empty my bladder often. /
17. My hands are usually cold and /

clammy.
18. My face gets hot and blushes. /
19. I have difficulty falling asleep easily /

and getting a good night’s rest.
20. I have nightmares. /
Please answer each question to the best of your ability.
1. Has there ever been a period of time when you were NOT YOUR USUAL SELF and ...
Yes No
... you felt so good or so hyper that other people thought you were not your /
normal self or you were so hyper that you got into trouble?
... you were so irritable that you shouted at people or started fights or /
arguments?
Has there ever been a period of time when you were NOT YOUR USUAL SELF and ...
Yes No
... you felt much more self-confident than usual? /
... you slept less than usual and were still energetic? /
... you were much more talkative or spoke much faster than usual? /
... thoughts raced through your head or you couldn’t slow your mind down? /
... you were so easily distracted by things around you that you had trouble /
concentrating or staying on track?
... you had much more energy than usual? /
... you were much more active or did many more things than usual? /
... you were much more social or outgoing than usual, for example, you /
telephoned friends in the middle of the night?
... you were much more interested in sex than usual? /
... you did things impulsively which other people might have considered to be /
excessive, foolish, or risky?
... spending money got you or your family into trouble? /
Yes No
2. If you checked YES to more than one of the above, have several of /
these ever happened DURING THE SAME PERIOD of time?
No Minor Moderate Serious

Problem Problem Problem Problem
3. How much of a problem did any of these /
cause you – like being unable to work; having
family conflict, money or legal troubles; getting
into arguments or fights?
For accurate results, you must be entirely honest in your response to all six questions in the test
below. To complete the test, check the box which best represents your level of agreement with
each statement.
Not Just a Somewhat Moderately Quite All the

at all little a lot time
1. I feel that other people /
or forces control what I
think and feel.
2. I hear or see things that /

others do not hear or
see.
3. I feel that I am being /

followed, monitored,
and observed.
4. I feel that people talk /

about me or give hidden
messages about me.
5. I have magical powers /

that nobody else has or
can explain.
6. I believe that others are /

plotting to get me, harm
me, or kill me.
Please check the box which best reflects how each statement applies to you. The items below
refer to how you have felt and behaved during most of your adult life. If you have usually been
one way and recently have changed, your response should reflect how you have usually been.
Never Rarely Sometimes Often Very

Often
1. I have difficulty finishing the final /
details of a project, even if the
challenging parts have already been
done.
Never Rarely Sometimes Often Very
Often
2. I have difficulty with tasks that /
require organization (getting things in
order).
3. I have difficulty remembering /

appointments or obligations.
4. I avoid or delay getting started on /

tasks that require a lot of mental
effort.
5. I fidget or squirm with my hands or /

feet when I have to sit down for a
long time.
6. I feel overly active and compelled to /

do things, as if I was driven by a
motor.
Please check the box which best reflects how each statement applies to you. The items below
refer to how you have felt and behaved during most of your adult life. If you have usually been
one way and recently have changed, your response should reflect how you have usually been.
Does not Rarely Occasionally Frequently Always

apply
1. I find that I stay online /
longer than I intended.
2. I neglect household /
chores to spend more
time online.
3. I prefer the excitement of /

the internet to intimacy
with my partner.
4. I choose to spend more /

time online over going
out with others.
Does not Rarely Occasionally Frequently Always

apply
5. Other people in my life /
complain to me about the
amount of time I spend
online.
6. My grades or school /
work/ job performance
suffer because of the
online.
7. I find myself imagining /

and anticipating when I
will go online again.
8. I find myself saying “just /

a few more minutes”
when online.
9. I snap, yell, or act /

annoyed if someone
bothers me while I am
online.
10. I lose sleep because I stay /

too long on the internet.
11. I try to cut down the /

online but I fail.
12. I try to hide how long I’ve /

been online.
13. I feel depressed, moody, /

or nervous when I am
offline, and I feel good
again as soon as I am
back online.
Please check the box which best reflects how each statement applies to you. The questions
refer to your feelings and behaviour over your whole life. Carefully read each statement and
decide whether your answer is “Yes” or “No.” Please give the best answer or the answer that
is right most of the time.
Does not N Ye
apply o s
1. Have you ever felt you should cut down on your drinking? /
2. Have people annoyed you by criticising your drinking? /
3. Have you ever felt bad or guilty about your drinking? /
4. Have you ever had a drink first thing in the morning to steady /
your nerves or get rid of a hangover (eye-opener)?
Are you troubled by the following: No Ye

s
1. An intense and persistent fear of social situations wherein people might /
judge you.
2. Fear that you will be humiliated by your actions. /
3. Fear that people will notice that you are blushing, sweating, trembling or /
showing other signs of anxiety.
4. Knowing that your fear is excessive or unreasonable. /
5. Go to great lengths to avoid participating in social activities. /

6. Have your symptoms interfere with your daily life. /
When the words “drug abuse” are used, they mean the use of prescribed or over‐the‐counter
medications/drugs in excess of the directions and any non‐medical use of drugs.
The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents,
tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., shabu), hallucinogens
(e.g., LSD) or narcotics (e.g., heroin).
Remember that the questions DO NOT INCLUDE ALCOHOL OR TOBACCO.
If you have difficulty with a statement, then choose the response that is mostly right.
These questions refer to the last 12 months: No Ye

s
1. Have you used drugs other than those required for medical reasons? /
2. Do you abuse more than one drug at a time? /
3. Are you always able to stop using drugs when you want to? (If you never /
used drugs, answer “Yes.”)
4. Have you had “blackouts” or “flashbacks” as a result of drug use? /
5. Do you ever feel bad or guilty about your drug use? (If you never use drugs, /
choose “No.”)
6. Does your spouse (or parents) ever complain about your involvement with /
drugs?
7. Have you neglected your family because of your use of drugs? /
8. Have you engaged in illegal activities in order to obtain drugs? /
9. Have you ever experienced withdrawal symptoms (felt sick) when you /
stopped taking drugs?
10. Have you had medical problems as a result of your drug use (e.g., memory /
loss, hepatitis, convulsions, bleeding, etc.)?
Ye No
s
1. Have you ever felt the need to bet more and more money? /
2. Have you ever had to lie to people important to you about how much you /
gambled?
The purpose of the questions below is for you to describe the kind of person you are. When
answering the questions, think about how you have tended to feel, think, and act over the past
several years. To remind you of this, on the top of each page you will find the statement: “Over
the past several years...” Check the box which best represents your personality. There are no
correct answers.
Over the past several years ... Tru Fals

e e
1. I know that people will take advantage of me, or try to cheat me, if I let /
them.
2. I often wonder whether the people I know can really be trusted. /
3. Others will use what I tell them against me. /
4. I keep alert to figure out the real meaning of what people are saying. /
5. I never forget, or forgive, those who do me wrong. /

6. I get back at people who insult me. /
7. I often wonder whether my partner has been unfaithful to me. /

e e
1. Spending time w/family or friends just doesn’t interest me. /
2. I would rather do things by myself than with other people. /
3. Sex just doesn’t interest me. /
4. I have an interest in only a few activities. /
5. I am not interested in having close friends. /
6. I don’t care what others have to say about me. /
7. I keep my distance from others. /

e e
1. I get special messages from things happening around me. /
2. I have the ability to know that some things will happen before they /
actually do.
3. I can often sense, or feel things, that others can’t. /
4. People often have difficulty understanding what I tell them. /
5. I am not interested in having close friends. /

6. I am often on guard against being taken advantage of. /
7. I have difficulty relating to others in a one-to-one situations. /
8. People have the initial impression that I’m odd, eccentric or weird. /
9. Being around other people makes me nervous. /

e e
1. I need to be the center of attention. /
2. I am “sexier” than most people. /
3. I show my emotions easily. /
4. I use my “looks” to get the attention that I need. /
5. Even though I talk a lot, people say that I have trouble getting to the /
point.
6. I have a flair for the dramatic. /
7. I am easily influenced by others. /
8. I quickly feel close to people whom I have just met. /

e e
1. I am better and superior than most people. /
2. I often imagine about being more successful, powerful, and brilliant. /
3. I am a unique and special person, and thus, only unique and special /
people can really appreciate and understand me.
4. I very much need other people to take notice of me or admire me. /

5. I expect other people to give me special treatment and to comply with /
my expectations.
6. Some people think that I take advantage of others. /
7. People have often complained that I arrogant and uncaring. /
8. Many people are envious of me. /
9. Others consider me to be uncaring. /

e e
1. I’ll go to extremes to prevent those who I love from ever leaving me. /
2. I either love someone or hate them, with nothing in between. /
3. I often wonder who or what I really am. /
4. I have tried to hurt or kill myself. /
5. I am a very moody person. /
6. I feel that my life is dull, empty, and meaningless. /
7. I have difficulty controlling my anger, or temper. /
8. When I am stressed, I can become paranoid or just “black out.” /

I act impulsively and do things that could get me into trouble such as:
 1. Spending more money than I should
 2. Having sex with people I hardly know
 3. Drinking too much
 4. Taking drugs
 5. Binge-eating
 6. Reckless driving

e e
1. I avoid working with people who may criticize me. /
2. I make friends with people only when I am sure they like me. /
3. I am inhibited in my intimate relationships because I am afraid of being /

ridiculed.
4. I am more sensitive to criticism or rejection than most people. /
5. I am afraid to meet new people because I feel inadequate. /
6. I suffer from low self esteem. /
7. In new situations, I fear being embarrassed. /

e e
1. I’ve been in trouble with the law several times (or would have been if I /
had been caught).
2. I get into a lot of physical fights. /
3. I have difficulty paying bills because I don’t stay at any one job for very /
long.
4. I do a lot of things impulsively without considering the consequences. /
5. It is easy for me to lie and I often do it. /
6. I enjoy doing risky things. /
7. I don’t care if others get hurt so long as I get or do what I want. /

When I was a kid (before age 15), I was somewhat of a juvenile delinquent, doing some of
the things below:
 1. I was considered a bully.
 2. I used to start fights with other kids.
 3. I used a weapon in fights that I had.
 4. I robbed or mugged other people.
 5. I was physically cruel to other people.
 6. I enjoyed making animals suffer.
 7. I forced others to have sex with me.
 8. I lied a lot.
 9. I stayed out at night without my parents’ permission.
 10. I stole things from others.
 11. I set fires.
 12. I broke windows or destroyed property.
 13. I ran away from home overnight more than once.
 14. I began skipping school a lot, in grade school and high school.
 15. I broke into someone’s house, building or car.

e e
1. I can’t make decisions without the advice, or reassurance of others. /
2. I prefer that other people assume responsibility for me. /
3. I fear losing the support of others if I disagree with them. /
4. I find it difficult to start something if I have to do it by myself. /
5. I want people to like me so much that I volunteer to do things that I /

would rather not do.
6. When alone, I feel helpless and unable to care for myself. /
7. When a close relationship ends, I need to get involved with someone else /
immediately.
8. I am terrified of being left alone to care for myself. /

e e
1. I am organized and detailed in what I do by making lists and schedules. /
2. I waste time trying to make things too perfect. /
3. I put my work ahead of having fun or of being with my family and /

friends.
4. I strictly follow my morals and values and have a strong sense of what is /
right or wrong.
5. I accumulate and keep a lot of things that I don’t need but I can’t bear to /
throw out.
6. If others can’t do things correctly, I would prefer to do the work myself. /
7. I see myself as thrifty but others see me as being cheap and miserly. /
8. People complain that I’m rigid and stubborn. /

e e
1. I delay or avoid doing what I’m supposed to do and thus, others perceive /
me as inefficient or irresponsible.
2. I feel misunderstood and unappreciated by others. /
3. I often criticize and scorn authority figures. /
4. I can get moody and argumentative. /
5. I envy and feel resentful towards those who are luckier, more fortunate, /
or more successful than me.
6. I frequently express to others about how my personal misfortune. /
7. I am often rebellious but later on, I feel regretful and apologetic for the /
wrong I’ve done.
True Fals
e
1. Sometimes I get upset. /
2. Occasionally I talk about people behind their backs. /
3. There are some people I don’t like. /
4. I have never told a lie. /
True Fals
e
1. A nuclear war may not be such a bad idea. /
2. I have lied a lot on this questionnaire. /

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Reminders: Kindly print out these 17 sheets. Write your name on all sheets.

A little of Some of Good part Most of

2. Morning is when I feel the worst. /

3. I have crying spells or feel like it. /

4. I have trouble sleeping at night. /

5. I do not eat as I used to. /

6. I do not enjoy sex as I used to. /

7. I notice that I am losing weight. /

8. I have trouble with constipation. /

9. My heart beats faster than usual. /

10. I get tired for no reason. /

11. My mind is not as clear as it used to be. /

12. I find it difficult to do the things I used /

13. I am restless and can’t keep still. /

14. I feel hopeless about the future. /

16. I find it difficult to make decisions. /

17. I feel that I am useless and unneeded. /

18. My life is empty. /

19. I feel that others would be better off if I /

20. I do not enjoy the things I used to do. /

A little of Some of Good part Most of

2. I feel afraid for no reason at all. /

3. I get upset easily or feel panicky. /

4. I feel like I’m falling apart and going to /

5. I feel that not all is well and that /

6. My arms and legs shake and tremble. /

7. I am bothered by headaches neck and /

8. I feel weak and get tired easily. /

10. I can feel my heart beating fast. /

11. I am bothered by dizzy spells. /

12. I have fainting spells or feel like it. /

13. I have difficulty breathing in and out /

14. I get numbness and tingling in my /

15. I am bothered by stomach aches or /

16. I have to empty my bladder often. /

17. My hands are usually cold and /

18. My face gets hot and blushes. /

19. I have difficulty falling asleep easily /

20. I have nightmares. /

Please answer each question to the best of your ability.

... you had much more energy than usual? /

... you were much more interested in sex than usual? /

... spending money got you or your family into trouble? /

No Minor Moderate Serious

Not Just a Somewhat Moderately Quite All the

2. I hear or see things that /

3. I feel that I am being /

4. I feel that people talk /

5. I have magical powers /

6. I believe that others are /

Never Rarely Sometimes Often Very

3. I have difficulty remembering /

4. I avoid or delay getting started on /

5. I fidget or squirm with my hands or /

6. I feel overly active and compelled to /

Does not Rarely Occasionally Frequently Always

3. I prefer the excitement of /

4. I choose to spend more /

Does not Rarely Occasionally Frequently Always

7. I find myself imagining /

8. I find myself saying “just /

9. I snap, yell, or act /