Measurement

1. Little Interest or Pleasure in Doing Things

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

2. Feeling Down, Depressed, or Hopeless

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

3. Trouble Falling/Staying Asleep, or Sleeping Too Much

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

4. Feeling Tired or Having Little Energy

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

5. Poor Appetite or Overeating

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

6. Feeling Bad About Yourself — or That You Are a Failure

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

7. Trouble Concentrating on Things

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

8. Moving or Speaking Slowly, or Restless/Fidgety

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

9. Thoughts of Being Better off Dead or Hurting Yourself

Not at AllSeveral DaysMore Than Half the DaysNearly Every Day

Activity Review

Activities completed this week:

Overall mood rating (0–10):

Mastery / Pleasure rating:

Values Alignment

Values domains addressed:

Relationships / Family

Work / Career

School / Education

Health / Self-care

Recreation / Enjoyment

Spirituality / Meaning

Community / Service

Avoidance Patterns

Avoidance pattern identified:

Function of avoidance:

Activity Planning

Scheduled activity for next week:

Graded step (if needed):

Predicted barriers:

Support person:

Plan

SMART action for next week:

Review date:

Follow-up:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Measurement

PHQ-9

Over the past 2 weeks, how often have you been bothered by… ⓘ

Activity Review

Values Alignment

Avoidance Patterns

Activity Planning

Plan

Plan and Follow-Up

Counseling - Behavioral Activation Template

Preview