Name
* Required
NHS number
Date of birth
* Required
Contact number
* Required
Group/course name
* Required
When I take a shower or a bath, I stay alert to the sensations of water on my body
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I'm good at finding words to describe my feelings
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I don't pay attention to what I'm doing because I'm daydreaming, worrying, or otherwise distracted
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I think some of my thoughts are abnormal or bad and I shouldn't think that way
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
When I have distressing thoughts or images, I "step back" and am aware of the thought or image without getting taken over by it
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I notice how foods and drinks affect my thoughts, bodily sensations, and emotions
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I have trouble thinking of the right words to express how I feel about things
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I do jobs or tasks automatically without being aware of what I'm doing
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I think some of my emotions are bad or inappropriate and I shouldn't feel them
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
When I have distressing thoughts or images I am able just to notice them without reacting
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I pay attention to sensations, such as the wind in my hair or sun on my face
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
Even when I'm feeling terribly upset I can find a way to put it into words
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I find myself doing things without paying attention
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
I tell myself I shouldn't be feeling the way I'm feeling
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
When I have distressing thoughts or images I just notice them and let them go
* RequiredNever or very rarely true Rarely true Sometimes true Often true Very often or always true
