o

o
o
o

Urge to Feel
o

Felt

Looked

Picked #__________

Hair pulling

Urge to Look
Urge to Pick
Urge to Pull
#________

Situation:
o

Car
_____ Lunchtime _______ Morning Drive
________ Afterwork drive _______ Nighttime
_________ To Social Event Drive _____ Weekend Drive _________To exercise

Bedroom
_____ After shower

o
o
o
o
o

_________Before Bed

_______Something coming up?____________

Bathroom
Classroom
School Bathroom
Living room/Kitchen
Other_____________________________________

First Thought or Emotion

o
o
o
o
o
o
o
o

Im curious how this looks/feels

This probably looks/feels bad
I dont like how this looks/feels
I dont want to be thinking about this/Cant stand thinking about this
I need to get this out or else
I want that burst/relief/flat feeling
Pure habit, no awareness
General anxiety

Alternative thought attempted?

o
o

YES___________________________________________________________________________
_____Helpful
____ Not Helpful
NO

HRT Attempted
o
o

YES____________________________________________________________________________
_____Helpful
_____Not Helpful
NO

TIME UNDER TRANCE

_____15 sec ____30 sec _____1 min _____2 min _____3 min
EFFORT LEVEL
1 2 3 4 5 6 7 8 9 10

_____5 min

_____10 min _____15 min

AWARENESS LEVEL
1 2 3 4 5 6 7 8 9 10