Separation Anxiety Disorder Assessment-Adult Self Report

Assessment 1 of 13

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

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Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. During the PAST 7 DAYS, I have felt moments of sudden terror, fear, or fright when separated
2. During the PAST 7 DAYS, I have felt anxious, worried, or nervous about being separated
3. During the PAST 7 DAYS, I have had thoughts of bad things happening to people important to me or bad things happening to me when separated from them (e.g., getting lost, accidents)
4. During the PAST 7 DAYS, I have felt a racing heart, sweaty, trouble breathing, faint, or shaky when separated
5. During the PAST 7 DAYS, I have felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping when separated
6. During the PAST 7 DAYS, I have avoided going places where I would be separated
7. During the PAST 7 DAYS, I have when separated, left places early to go home
8. During the PAST 7 DAYS, I have spent a lot of time preparing for how to deal with separation
9. During the PAST 7 DAYS, I have distracted myself to avoid thinking about being separated
10. During the PAST 7 DAYS, I have needed help to cope with separation (e.g., alcohol or medications, superstitious objects)