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Intake — CORE-10

A brief check-in.

Ten questions about the last week. Take your time — there are no right answers.

Your name *

Date

Important — please read first

This form has 10 statements about how you have been over the last week. Read each statement and choose the option that’s closest to how often you felt that way.

Over the last week…

Tap one option per row. You can leave up to 1 blank.

Not at all

Only occasionally

Sometimes

Often

Most or all the time

1.I have felt tense, anxious or nervous

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

2.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•

3.I have felt able to cope when things go wrong

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

4.Talking to people has felt too much for me

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

5.I have felt panic or terror

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

6.I made plans to end my life

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

7.I have had difficulty getting to sleep or staying asleep

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

8.I have felt despairing or hopeless

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

9.I have felt unhappy

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

10.Unwanted images or memories have been distressing me

Not at all•Only occasionally•Sometimes•Often•Most or all the time•

0 of 10 answered — please answer at least 9.

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