I understand this survey is for personal reflection and program improvement. It is not a clinical assessment or diagnosis. If I am experiencing significant distress, I understand I should reach out to a licensed mental health professional or emergency services *

I understand and consent to continue

Part 1:

Instructions: Over the last 2 weeks, how often have you been bothered by any of the following problems?

Response Options for Part 1 Questions:
0 - Not at all
1 - Several Days
2 - More than half the days

3 - Nearly every day

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Little interest or pleasure in doing things *

Not at all

Several days

More than half the days

Nearly every day

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Feeling down, depressed, or hopeless *

Not at all

Several days

More than half the days

Nearly every day

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Trouble falling or staying a sleep, or sleeping too much *

Nat at all

Several days

More than half the days

Nearly every day

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Feeling tired or having little energy *

Not at all

Several days

More than half the days

Nearly every day

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Poor appetite or overeating *

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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Trouble concentrating on things, such as reading or watching TV *

Not at all

Several days

More than half the days

Nearly every day

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Moving or speaking so slowly that other people have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual *

Not at all

Several days

More than half the days

Nearly every day

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Thoughts that you would be better off dead or of hurting yourself in some way *

Not at all

Several days

More than half the days

Nearly every day

Part 2:

Instructions: Over the last 2 weeks, how often have you been bothered by the following problems?

Response Options for Part 2 Questions:
0 - Not at all
1 - Several days
2 - More than half the days

3 - Nearly every day

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Feeling nervous, anxious, or on edge *

Not at all

Several days

More than half the days

Nearly every day

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Not being able to stop or control worrying *

Not at all

Several days

More than half the days

Nearly every day

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Worrying too much about different things *

Not at all

Several days

More than half the days

Nearly every day

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Trouble relaxing *

Not at all

Several days

More than half the days

Nearly every day

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Being so restless that it's hard to sit still *

Not at all

Several days

More than half the days

Nearly every day

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Becoming easily annoyed or irritable *

Not at all

Several days

More than half the days

Nearly every day

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Feeling afraid as if something awful might happen *

Not at all

Several days

More than half the days

Nearly every day

Part 3:

⚠️ IMPORTANT: The following questions have 6 response options instead of 4.

Instructions: Below are five statements with which you may agree or disagree. Please indicate for each of the five statements which is closest to how you have been feeling over the last two weeks.

Response Options for Part 3 Questions:
0 - At no time
1 - Some of the time
2 - Less than half the time

3 - More than half the time
4 - Most of the time

5 - All of the time

Part 4:

Instructions: Next is a list of statements dealing with your general feelings about your self. Please indicate how strongly you agree or disagree with each statement.

Response Options for Part 4 Questions:
1 - Strongly Disagree
2 - Disagree

3 - Agree
4 - Strongly Agree

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On the whole, I am satisfied with myself *

Strongly Disagree

Disagree

Agree

Strongly Agree

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I feel that I have a number of good qualities *

Strongly Disagree

Disagree

Agree

Strongly Agree

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I am able to do things as well as most other people *

Strongly Disagree

Disagree

Agree

Strongly Agree

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I take a positive attitude toward myself *

Strongly Disagree

Disagree

Agree

Strongly Agree

Part 5:

Instructions: The following questions relate to your usual sleep habits during the past month only.

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During the past month, how would you rate your sleep quality overall? *

Very Good

Fairly Good

Fairly Bad

Very Bad

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During the past month, how often have you had trouble sleeping because you cannot get to sleep within 30 minutes *

Not during the past month

Less than once a wekk

Once or twice a week

Three or more times a week

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During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning? *

Not during past month

Less than once a week

Once or twice a week

Three or more times a week

Part 6:

Instructions: How often do you feel the way described in each of the following statements?

Response Options for Part 6:
1 - Never
2 - Rarely
3 - Sometimes
4 - Often

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How often do you feel that you lack companionship? *

Never

Rarely

Sometimes

Often

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How often do you feel left out? *

Never

Rarely

Sometimes

Often

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How often do you feel isolated from others *

Never

Rarely

Sometimes

Often

Part 7:

Instructions: The following questions relate to specific areas of your current life experience.

38 of 45

In the past month, how often has pornography use interfered with your daily life, relationships, or responsibilities? *

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