CORE 34 (adapted) & Supplement 2

Please fill out ALL fields.

Client Details

Course Code*

Initials*

Date of Birth*

This evaluation form is to be completed at the end of the course and at any follow up stage to measure general psychological health. This will be compared to the evaluation forms completed at the beginning of the course to measure your progress in recovery and the efficacy of the course. All personal information will remain confidential and your anonymity will be safeguarded. Please answer the following questions based on how you felt during the past week.

1. I have felt terribly alone and isolated*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

2. I have felt tense, anxious or nervous*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

3. I have felt I have someone to turn to for support when needed*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

4. I have felt O.K. about myself*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

5. I have felt totally lacking in energy and enthusiasm*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

6. I have been physically violent to others*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

7. I have felt able to cope when things go wrong*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

8. I have been troubled by aches, pains or other physical problems*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

9. I have thought of hurting myself*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

10. Talking to people has felt too much for me*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

11. Tension and anxiety have prevented me doing important things*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

12. I have been happy with the things I have done*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

13. I have been disturbed by unwanted thoughts and feelings.*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

14. I have felt like crying.*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

15. I have felt panic or terror*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

16. I made plans to end my life*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

17. I have felt overwhelmed by my problems*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

18. I have had difficulty getting to sleep or staying asleep*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

19. I have felt warmth or affection for someone*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

20. My problems have been impossible to put to one side*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

21. I have been able to do most things I needed to*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

22. I have threatened or intimidated another person*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

23. I have felt despairing or hopeless*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

24. I have thought it would be better if I were dead*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

25. I have felt criticised by other people*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

26. I have thought I have no friends*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

27. I have felt unhappy*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

28. Unwanted images or memories have been distressing me*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

29. I have been irritable when with other people*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

30. I have thought I am to blame for my problems and difficulties*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

31. I have felt optimistic about my future*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

32. I have achieved the things I wanted to*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

33. I have felt humiliated or shamed by other people*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

34. I have hurt myself physically or taken dangerous risks with my health*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

CSBD Supplement 2

This evaluation form is to be completed to measure your acting out behaviours. Please answer the following questions based on an average recovery period since last completing an evaluation form.

1.How often have you engaged in addictive sexual behaviour?*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

2. How often have you fantasised about your addictive sexual behaviour?*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

3. How often have your struggled with intrusive thoughts and feelings about your addictive sexual behaviour?*

Not at all
Only Occasionally
Sometimes
Often
Most or all the time

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Total except R

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All Mean

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All Mean Except R