Service Application

Please read each of the following sentences carefully, and circle a number on the right to indicate how "the past week" applies to you. There is no right or wrong answer. Please don't spend too much time on a sentence.

0=not applicable; 1=quite applicable, or occasionally applicable; 2=very applicable, or often applicable; 3=most applicable, or often applicable

The social worker of Tsz Shan Monastery Buddhist Spiritual Counselling Centre will contact you within 3 working days after receiving the questionnaire results and follow up your needs.

Email Address*

1. I find it difficult to calm myself down*

0

1

2

3

2. I feel dry mouth*

0

1

2

3

3. I don’t seem to have any more pleasant and comfortable feelings*

0

1

2

3

4. I have difficulty breathing (for example, I feel short of breath or breathless when not doing exercise)*

0

1

2

3

5. I find it hard to motivate myself to work*

0

1

2

3

6. I am always overly sensitive*

0

1

2

3

7. I feel trembling (for example, shaking hands)*

0

1

2

3

8. I feel I consume a lot of energy*

0

1

2

3

9. I worry about occasions that make me panic or make a fool of myself*

0

1

2

3

10. I feel that I have no hope for the future*

0

1

2

3

11. I feel uneasy*

0

1

2

3

12. I find it hard to relax*

0

1

2

3

13. I feel depressed*

0

1

2

3

14. I can't tolerate anything that prevents me from continuing to work*

0

1

2

3

15. I feel about to panic*

0

1

2

3

16. I can't be passionate about anything*

0

1

2

3

17. I feel that I am unworthy to be a Human*

0

1

2

3

18. I find that I am easily offended*

0

1

2

3

19. I noticed that even when there was no obvious physical work, I felt my heart rhythm was abnormal*

0

1

2

3

20. I feel scared for no reason*

0

1

2

3

21. I feel life is meaningless*

0

1

2

3

Service applicant name (full name in Chinese)*

Gender*

Age*

Contact Number (Mobile Phone)*

A convenient time for contact*

* I agree that the social worker of the Tsz Shan Monastery Buddhist Spiritual Counselling Centre will contact me

Quoted from Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd ed.) Sydney: Psychology Foundation. (Chinese version translated by Dr. Chen Qianyuan)

Online Wellness Assessment (DASS21)