01732 808 626 info@thinkcbt.com

01732 808 626 info@thinkcbt.com

01732 808 626 info@thinkcbt.com

Severity of Dissociative Symptons (DSM-5 Assessment)
You can respond anonymously, and no data will be retained from this assessment. If you choose to include your initials and an email address, your results will be automatically sent to the email address provided. Please check that the email address has been entered correctly before submitting this form. All client information is managed on a strictly confidential basis. Please Note: Whilst every effort is made to ensure that our system is securely encrypted, email is not a completely secure means of communication. Think CBT does not accept liability for loss or theft of personal data where any individual chooses to transmit or receive information via email.
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This questionnaire is not designed to provide a definitive psychological diagnosis or to take the place of a professional consultation. Please answer all questions as accurately and honestly as possible.


For each statement below, please check the box that best answers each question to show how much each
thing has happened to you in the past SEVEN (7) DAYS.

1. I find myself staring into space and thinking of nothing.

2. People, objects, or the world around me seem strange or unreal.

3. I find that I did things that I do not remember doing.

4. When I am alone, I talk out loud to myself.

5. I feel as though I were looking at the world through a fog so that people and things seem far away or unclear.

6. I am able to ignore pain.

7. I act so differently from one situation to another that it is almost as if I were two different people.

8. I can do things very easily that would usually be hard for me.