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Name
Sex
Write in numbers
Please list your father, mother, sisters, brothers, step family relations, or other family members who had a significant effect on your life (either positive or negative).
HAVE YOU SEEN A COUNSELOR BEFORE?
if yes please list here below
Have your family mebers or friends ever attempted or commited suicide?
Check any of the following symptoms or problems that you currently are or recently have experienced:
How Distressed would you say you are feeling today?
Are you currently experiencing any desire to die?
Have you experienced any desire to die in the past?
Have you attempted suicide in the past?
Are you currently experiencing any harmful or fearful feelings?