Instructions to Staff: Please fill in the following information.

Site Number: -
Admission/
Patient ID Number: Intake Date:
Month Day Year
Time Point: 1 = Admission/Intake 3 = Discharge/Termination Level of Care: 1 = Inpatient 3 = Partial/Day Hospital
2 = Mid-Treatment 4 = Post-Treatment Follow-up.... 2 = Outpatient 4 = Residential…….….
Program Type: 1 = general adult 2 = child/adolescent 3 = geriatric 4 = affective/mood disorders 5 = psychotic disorders
6 = anxiety disorders/trauma 7 = substance abuse/chemical dependency 8 = dual diagnosis 9 = other………………….
BASIS-32™ (Behavior And Symptom Identification Scale)
Instructions To Respondent: Below is a list of problems and areas of life functioning in which some people experience difficulties.
Using the scale below, fill in the box with the answer that best describes how much difficulty you have been having in each area
DURING THE PAST WEEK. 0 = No Difficulty
1 = A Little Difficulty
2 = Moderate Difficulty
3 = Quite A Bit of Difficulty
4 = Extreme Difficulty
Please answer each item. Do not leave any blank.
If there is an area that you consider to be inapplicable, indicate that it is 0=No Difficulty.
IN THE PAST WEEK, how much difficulty have you been having in the area of:

1. Managing day-to-day life. (For example, getting places on time, handling money, making everyday decisions)..........1

2. Household responsibilities. (For example, shopping, cooking, laundry, cleaning, other chores)....................................2

3. Work. (For example, completing tasks, performance level, finding/keeping a job).........................................................3

4. School. (For example, academic performance, completing assignments, attendance)......................................................4

5. Leisure time or recreational activities.............................................................................................................................5

6. Adjusting to major life stresses. (For example, separation, divorce, moving, new job, new school, a death)................6

7. Relationships with family members.................................................................................................................................7

8. Getting along with people outside of the family..............................................................................................................8

9. Isolation or feelings of loneliness......................................................................................................................................9

10. Being able to feel close to others...................................................................................................................................10

11. Being realistic about yourself or others.......................................................................................................................11

12. Recognizing and expressing emotions appropriately.................................................................................................12

13. Developing independence, autonomy...........................................................................................................................13

14. Goals or direction in life................................................................................................................................................14

15. Lack of self-confidence, feeling bad about yourself....................................................................................................15

16. Apathy, lack of interest in things.................................................................................................................................16

17. Depression, hopelessness...............................................................................................................................................17

18. Suicidal feelings or behavior.........................................................................................................................................18

19. Physical symptoms. (For example, headaches, aches and pains, sleep disturbance, stomach aches, dizziness)...........19

20. Fear, anxiety, or panic...................................................................................................................................................20

21. Confusion, concentration, memory.........................................................................................................................…..21

© COPYRIGHT McLean Hospital Department of Mental Health Services Evaluation (B32.0108)

 0 = No Difficulty
1 = A Little Difficulty
2 = Moderate Difficulty
3 = Quite A Bit of Difficulty
4 = Extreme Difficulty

IN THE PAST WEEK, how much difficulty have you been having in the area of:

22. Disturbing or unreal thoughts or beliefs............................................................................................................….22

23. Hearing voices, seeing things...........................................................................................................................….....23

24. Manic, bizarre behavior...........................................................................................................................................24

25. Mood swings, unstable moods..................................................................................................................................25

26. Uncontrollable, compulsive behavior. (For example, eating disorder, hand-washing, hurting yourself)...............26

27. Sexual activity or preoccupation..............................................................................................................................27

28. Drinking alcoholic beverages...................................................................................................................................28

29. Taking illegal drugs, misusing drugs.......................................................................................................................29

30. Controlling temper, outbursts of anger, violence...................................................................................................30

31. Impulsive, illegal, or reckless behavior....................................................................................................................31

32. Feeling satisfaction with your life............................................................................................................................32

For the following questions, please write the response code in the appropriate box.
33. How old were you on your last birthday? (age in years)…………………………………………..........….….....33

34. What is your sex? 1 = Male 2 = Female…..……………………………………………………........…....34

35. What is your race? 1 = Black/African American 3 = Asian/Pacific Islander 5 = Multiracial/
2 = White/Caucasian 4 = American Indian/Alaskan Other.………......35

36. Are you Hispanic or Latino? 1 = Yes 2 = No……….……………………………….....…………36

37. What is your marital status? 1 = Never married 3 = Separated 5 = Widowed
2 = Married 4 = Divorced……………….……….….…..……………..37
38. Outside of your treatment providers, 1 = Spouse/partner 3 = Friends/roommates 5 = Other
what is your main source of social support? 2 = Other family 4 = Community/church 6 = None… 38
39. How much school have 1 = 8th grade or less 3 = High school graduate/GED 5 = 4-year
you completed? 2 = Some high school 4 = Some college college graduate…..39

40. In the past 30 days, what were 1 = Hospital or detox center 4 = Apartment or house
your USUAL living arrangements? 2 = Nursing home/assisted living 5 = Shelter/street
3 = Residential center/halfway house/ 6 = Jail/prison
Group home/board & care home/supervised housing 7 = Other………………….…40

41. At any time in the past 30 days, 1 = No 3 = Yes, 11 - 30 hours per week
did you work at a paying job? 2 = Yes, 1-10 hours per week 4 = Yes, more than 30 hours per week………..41
42. At any time in the past 30 days, 1 = No 3 = Yes, 11- 30 hours per week
did you work at a volunteer job? 2 = Yes, 1-10 hours per week 4 = Yes, more than 30 hours per week.…..…..42

43. At any time in the past 30 days, were you a student at a high school,
job training program, college or university degree program? 1 = Yes 2 = No………..…..... 43

44. Today’s date…………………………………….…………………………44

Month Day Year

© COPYRIGHT McLean Hospital Department of Mental Health Services Evaluation (B32.0108)