Each statement below describes how a person might feel when starting therapy or approaching problems in their lives. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel RIGHT NOW, not what you have felt in the past or would like to feel. For all statements that refer to your “problem,” answer in terms of problems related to why you are in therapy. The words “here” and “this place” refer to your treatment center or counselor’s office.

There are five possible responses to each of the items in the questionnaire:

1 = Strongly Disagree
2 = Disagree
3 = Undecided
4 = Agree
5 = Strongly Agree

Check the number that best describes how much you agree or disagree with each statement. Your responses will be confidentially sent to Dr. Guy Ilagan ONLY. He will score them and discuss the results with you in your initial (or next) meeting.


(University of Rhode Island Change Assessment Scale, Psychotherapy Version)