top of page

Insomnia Treatment Screening

Please questions below with the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Difficulty falling asleep
0 (None)
1 (Mild)
2 (Moderate)
3 (Severe)
4 (Vey Severe)
Difficulty staying asleep
0 (None)
1 (Mild)
2 (Moderate)
3 (Severe)
4 (Vey Severe)
Problems waking up too early
0 (None)
1 (Mild)
2 (Moderate)
3 (Severe)
4 (Vey Severe)
How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
0 (Very Satisfied)
1 (Satisfied)
2 (Moderately Satisfied)
3 (Dissatisfied)
4 (Very Dissatisfied)
How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
0 (Not At All Noticeable)
1 (A Little)
2 (Somewhat)
3 (Much)
4 (Very Much Noticeable)
How WORRIED/DISTRESSED are you about your current sleep problem?
0 (Not At All Worried)
1 (A Little)
2 (Somewhat)
3 (Much)
4 (Very Much Worried)
To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?
0 (Not At All Interfering)
1 (A Little)
2 (Somewhat)
3 (Much)
4 (Very Much Interfering)

Contact Us!

PHONE:       1-888-59-PSYCH

EMAIL:          help@telepsychservice.com
SUICIDE HOTLINE:      1-800-273-8255

Act Now logo-01.png

Serving Patients Online In California

bottom of page