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DSM-5 Level 1 Cross-Cutting Symptom Measure Assessment Form Template

Streamline Your Mental Health Assessments with Our Easy-to-Use Template

Managing diverse mental health symptoms can be overwhelming, especially when trying to meet diagnostic requirements. This DSM-5 Level 1 Cross-Cutting Symptom Measure Assessment Form Template is designed for mental health professionals like you, enabling effective evaluation of symptoms across various domains. Utilize this tool to simplify screening for anxiety, depression, and more, enhance client communication, streamline documentation, and ensure compliance with psychiatric guidelines-all while using user-friendly, WCAG-aligned labels. You can explore the live template now to see how it fits your practice.

Use this Template (FREE) Live Preview
Full name
Date of birth
If you prefer to self-describe your gender, please specify
Email
Phone number
Assessment date
Record ID or medical record number (if applicable)
Clinician or provider name (if applicable)
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
During the past 2 weeks, how much have you been bothered by: Little interest or pleasure in doing things?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling down, depressed, or hopeless?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling more irritated, grouchy, or angry than usual?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Sleeping less than usual, but still having a lot of energy?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Starting many more projects than usual or doing more risky things than usual?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling nervous, anxious, frightened, worried, or on edge?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling panic or being frightened?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Avoiding situations that make you nervous?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Unexplained aches and pains?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling that your illnesses are not being taken seriously enough?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Thoughts of actually hurting yourself?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Hearing things other people could not hear (such as voices) even when no one was around?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Problems with sleep that affected your sleep quality overall?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Problems with memory (for example, learning new information) or with attention (for example, concentrating)?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Unpleasant thoughts, urges, or images that repeatedly enter your mind?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling driven to perform certain behaviors or mental acts over and over again?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Feeling detached or distant from yourself, your body, your surroundings, or your memories?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Not knowing who you really are or what you want out of life?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Not feeling close to other people or not enjoying your relationships with them?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Drinking 4 or more alcoholic drinks in a single day?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Smoking any cigarettes, a cigar, or a pipe, or using snuff or chewing tobacco?
None
Slight
Mild
Moderate
Severe
During the past 2 weeks, how much have you been bothered by: Using medicines on your own (without a prescription, in greater amounts than prescribed, or for longer than prescribed), or using any illegal drugs?
None
Slight
Mild
Moderate
Severe
Type your full name as your electronic signature
Signature date
I understand this screening does not provide a diagnosis and I consent to share my responses for clinical review
Agree
Disagree
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Paper art illustration depicting the DSM-5 Level 1 Cross-Cutting Symptom Measure Assessment Form Template

When to use this form

Use this broad mental health screener when you need a quick, whole-person view across mood, anxiety, sleep, substance use, and related domains. It works well at intake for outpatient counseling, school clinics, and primary care to flag what needs follow-up. It is also useful before med checks and at each visit to track change and adjust care. For fuller background, pair your results with a Psychosocial assessment form. If you expect complex presentations, coordinate next steps with a Psychiatrist interview form. The results help you set priorities, choose targeted scales, plan brief interventions, and document progress.

Must Ask DSM-5 Level 1 Cross-Cutting Symptom Measure Assessment Questions

  1. Over the past two weeks, how often have you had little interest or pleasure in doing things?

    Anhedonia is a core sign of depression and often predicts functional impact. Clarity on frequency guides whether to prioritize behavioral activation, psychotherapy, or referral.

  2. Over the past two weeks, how often have you felt nervous, anxious, or on edge?

    Anxiety can drive avoidance and somatic complaints that derail care plans. Knowing severity helps you plan monitoring and select brief interventions that fit the setting.

  3. Over the past two weeks, how often have you had trouble falling or staying asleep?

    Sleep problems amplify mood and anxiety symptoms and can signal emerging mania. Tracking sleep informs coaching on routines and coordination around medication timing.

  4. In the past two weeks, how often have you used alcohol or drugs more than you intended?

    Substance use can worsen mood, disrupt sleep, and affect safety, skewing other scores. If responses suggest risk, follow up with the Alcohol and drug evaluation form to assess patterns and harms.

  5. In the past two weeks, how often have you had unusually high energy or needed less sleep without feeling tired?

    Elevated energy and reduced sleep may indicate hypomania or mania and change treatment direction. If present, add the Young mania rating scale (YMRS) form to quantify severity and track response.

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