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Email Address
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To what degree have the challenges of the past 30 days affected you?
No Problem
A Bit
Somewhat
A Lot
Extremely
Indicate how much these difficulties have interfered with these areas of your life
No Problem
A Bit
Somewhat
A Lot
Extremely
Family Life
Social Life
Work, School, or Home
General Health
How much have the following problems bothered you in the past seven days?
No Problem
A Bit
Somewhat
A Lot
Extremely
Nervousness or shakiness
Feeling Sad or Blue
Your heart pounding or racing
Feeling hopeless about the future
How much have the following problems bothered you in the past seven days?
No Problem
A Bit
Somewhat
A Lot
Extremely
Feeling everything is an effort
Feelings of guild or worthlessness
Suddenly feeling scared for no reason
In the past 30 days, how many days were you unable to work because of your problem?
Answer if you've had a drink or used drugs in the past 30 days.
Yes
No
Not Applicable
In the past 30 days, have you ever felt you ought to cut down on your drinking or drug use?
In the past 30 days, have people annoyed you by criticizing your drinking or drug use?
Please tell us how much you agree with the following statements regarding The Holman Group:
No Problem
A Bit
Somewhat
A Lot
Extremely
The information and resources I received from The Holman Group were useful.
My calls to The Holman Group were answered in a reasonable time.
The Holman Group staff was helpful.
If the need arose I would use services from The Holman Group again.
Please tell us how much you agree with the following statements regarding finding a clinician(s):
No Problem
A Bit
Somewhat
A Lot
Extremely
I was satisfied with the time I waited for my clinician(s) to make initial contact with me
I was satisfied with the travel Distance to my clinician(s)
I am satisfied with the services I received from my clinician(s)
Please answer the following questions based upon how you feel each statement describes you most of the time.
No Problem
A Bit
Somewhat
A Lot
Extremely
Many times I forget to put things back in their proper place
I start conversations
I am sometimes shy and inhibited
I make people feel at ease
I don't hold grudges for long
Please answer the following questions based upon how you feel each statement describes you most of the time.
No Problem
A Bit
Somewhat
A Lot
Extremely
I'm not very easily upset
I often feel tense
I am full of Ideas
I tend to be moody
I like to pay attention to details
Please answer the following questions based upon how you feel each statement describes you most of the time.
No Problem
A Bit
Somewhat
A Lot
Extremely
I don't like to talk alot
I have an active imagination
I am not interested in other people's problems
I am curious about many different things
I keep going until a task is finished
Please enter any additional comments/concerns you may have.
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