PLEASE PRINT!  BE BRIEF AND LEGIBLE!
ANSWER QUESTION C FIRST.  THEN ANSWER THE OTHER QUESTIONS.

A. ACTIVATING EVENT you recently experienced about which you became upset of disturbed.  (Examples:  "I went for a job interview."  "My mate screamed at me."   _______________________________________________________________________

B. Rational BELIEF or idea you had about his Activating Event.  (Examples:  It would be unfortunate if I were rejected for the job."  "How annoying to have my mate scream at me!") _______________________________________________________________________

B. Irrational BELIEF of idea you had about this Activating Event.  (Examples:  "It would be catastrophes if I were rejected for the job; I would be pretty worthless as a person."  "I can't stand my mate's screaming; she is horrible for screaming at me!")  _______________________________________________________________________

C. CONSEQUENCES OF irrational BELIEF (1B) about the Activating Event listed in Question A.  State here the one most disturbing emotion, behavior, or CONSEQUENCE you experienced recently.  (Examples:  "I was anxious."  "I was hostile."  "I had stomach pains."  _______________________________________________________________________

D. DISPUTING, questioning, or challenging you can use to change your irrational BELIEF (1B).  (Examples:  "Why would it be catastrophic and how would I become a worthless person if I were rejected for the job?"  "Why can't I stand my mate's screaming and why is she horrible for screaming at me?  _______________________________________________________________________

E. Cognitive EFFECT or answer you obtained from disputing your irrational BELIEF (1B).  (Examples:  AIt would not be catastrophic, but merely unfortunate, if I were rejected for the job; my giving a poor interview would not make me a worthless person.  Although I'll never like my mate's screaming, I can stand it; he or she is not horrible but merely a fallible person for screaming.  _______________________________________________________________________

E. Behavioral EFFECT or result of your DISPUTING your irrational BELIEF (1B).  (Examples:  AI felt less anxious.  AI felt less hostile to my mate.  AMy stomach pains vanished.)
_______________________________________________________________________

F. If you did not challenge your irrational BELIEF (1B).(Examples:  AI felt less anxious.  AI felt less hostile to my mate.  AMy stomach pains vanished.)
 _______________________________________________________________________

G. Activities you would most like to stop that you are now doing.
_______________________________________________________________________

H. Activities you would most like to start that you are not doing.
_______________________________________________________________________

I. Emotions and ideas you would most like to change.
_______________________________________________________________________

J. Check the item which describes how much you have worked at your last homework assignment(s):
(a)  almost every day     (b)  several times a week       (c) occasionally      (d) hardly ever.

K. How many times in the past week have you specifically worked at changing and DISPUTING your irrational BELIEFS (iBa)?

L. What other things have you specifically done to change your irrational BELIEFS and your disturbed emotional CONSEQUENCES?

M. Check the item which describes how much reading you have recently done of the material on rational-emotive therapy:     (a)  a considerable amount (b)  a moderate amount     (c) little or none.
 

N. Things you would now like to discuss most with your therapist or group: