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Intake — CORE-OM

A fuller picture.

Thirty-four questions across wellbeing, symptoms, functioning and risk. Allow yourself around ten minutes.

Your name *

Date

Important — please read first

This form has 34 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 3 blank.

Not at all

Only occasionally

Sometimes

Often

Most or all the time

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•

0 of 34 answered — please answer at least 31.

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