DASS-Y Pre Assessment

I got upset about little things

0 1 2 3

I felt dizzy, like I was about to faint

0 1 2 3

I did not enjoy anything

0 1 2 3

I had trouble breathing (e.g. fast breathing), even though I wasn't exercising and I was not sick.

0 1 2 3

I hated my life

0 1 2 3

I found myself over-reacting to situations

0 1 2 3

My hands felt shaky

0 1 2 3

I was stressing about lots of things

0 1 2 3

I felt terrified

0 1 2 3

There was nothing nice I could look forward to

0 1 2 3

I was easily irritated

0 1 2 3

I found it difficult to relax

0 1 2 3

I could not stop feeling sad

0 1 2 3

I got annoyed when people interrupted me

0 1 2 3

I felt like I was about to panic

0 1 2 3

I hated myself

0 1 2 3

I felt like I was no good

0 1 2 3

I was easily annoyed

0 1 2 3

I could feel my heart beating really fast, even though I hadn't done any hard exercise

0 1 2 3

I felt scared for no good reason

0 1 2 3

I felt that life was terrible

0 1 2 3

Section C: Consent
DATA PRIVACY CONSENT
Creative arts therapists are required to maintain a pictorial record of artwork produced during art therapy sessions. Typically, the creative arts therapist takes a digital photograph of the artworks. Clients may retain the original upon request and if appropriate from the therapeutic perspective of the art therapist. This consent can be withdrawn at any time without explanation by contacting RPS. Circle ‘YES’ or ‘NO’ as appropriate:
Statement	YES	NO
I consent to my artworks being photographed.
I give consent for photographs and videos of my artworks and session information to be used for documentation and discussion during clinical supervision.
I consent to RPS highlighting my story of therapeutic change to raise awareness about art therapy for education purposes, such as research and conferences. All personal information will be kept confidential.
I understand that the creative arts therapist(s) will adhere to professional guidelines and will not disclose personal information without my explicit consent, except in cases where there is reason to believe that I or others may be at risk of actual or potential harm.
Consent Type Client Consent & Acknowledgement Caregiver / Guardian Consent (Under 21)
Informed Consent and Acknowledgement by Client I (NRIC last 4 digits: ), hereby confirm that I understand and consent to the above.
For Caregivers of Clients under 21 years old I (NRIC last 4 digits: ), am the parent / legal guardian of the client (NRIC last 4 digits: ), who is under 21 years old .

RPS Clinical Pre-Questionnaire

Section A: DASS-Y

Section B: Mental Wellbeing

Section C: Consent