Dissociation Screening Assessment Form
Please answer the following questions to help assess dissociative experiences. Your responses are confidential and will assist in understanding your symptoms.
Full Name
*
First Name
Last Name
Age
*
Email Address
example@example.com
How often do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Very Often
Gaps in memory you can't explain
1
2
3
4
5
Feeling disconnected from your thoughts or body
6
7
8
9
10
Feeling as though the world around you isn't real (derealization)
11
12
13
14
15
Finding yourself in a place but not remembering how you got there
16
17
18
19
20
Feeling like you're observing yourself from outside your body
21
22
23
24
25
Have you ever been told by others that you seem to 'zone out' or act differently?
*
Yes
No
Not Sure
Please describe any dissociative experiences or symptoms you've noticed (optional)
Submit Assessment
Should be Empty: