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Practice Management Tips
Separation anxiety test: free ASA-27 PDF for adults
Free PDF 3 pages, print-ready Clinician-reviewed
A separation anxiety test measures how strongly a person fears being apart from the people they are closest to. This free PDF is the Adult Separation Anxiety Questionnaire (ASA-27), developed by Manicavasagar, Silove, Wagner and Drobny in 2003. Adults over 18 rate 27 statements from 0 to 3, giving a raw score between 0 and 81. A score of 22 or more suggests probable adult separation anxiety disorder, and 16 to 21 suggests some separation anxiety. It is a screening aid for adults only, not a diagnosis, and children need a different instrument.
Template details
- Template type
- Test
- Format
- Printable PDF, 3 pages
- Sections
- 1 section
- Fields to complete
- 29 fields
- Best for
- Practice Management Tips
Free download
Download your free Separation anxiety test
The Adult Separation Anxiety Questionnaire (ASA-27) for adults over 18, with 27 self-report items rated 0 to 3. Boxes for the raw score, percentile and description follow the items. It also includes the scoring guide with both cut-offs and a clinician sign-off section.
What’s inside
- Patient details: name, gender, age and date of assessment
- Instructions to rate only symptoms experienced as an adult over 18
- 27 adult separation anxiety statements, each rated on a 0 to 3 scale
- Raw score (0 to 81), percentile and description boxes for the result
- Scoring guide with the 16 and 22 cut-offs and three severity bands
- Clinician name, license ID, signature and date of assessment fields
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Key takeaways
A separation anxiety test is a screening aid for measuring symptom severity, not a standalone diagnosis.
This free PDF is the ASA-27, a 27-item self-report questionnaire for adults over 18 only.
Raw scores run from 0 to 81, and a score of 22 or more suggests probable adult separation anxiety disorder.
Children and adolescents need a different, age-validated instrument, such as the SCARED or the Spence Children’s Anxiety Scale.
Pair the questionnaire with DSM-5-TR criteria and a full clinical interview before forming a diagnosis.
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What is a separation anxiety test?
A separation anxiety test is a questionnaire that measures how intensely a person fears separation from attachment figures, such as a partner, parent or child. The version on this page is the Adult Separation Anxiety Questionnaire (ASA-27), a self-report screen developed by Manicavasagar, Silove, Wagner and Drobny in 2003.
Practitioners use it at intake, at baseline and to track change over treatment. Results support documentation and the clinical conversation, but they do not replace a full diagnostic evaluation.
What the ASA-27 asks about
DSM-5-TR defines separation anxiety disorder by fear or anxiety about separation from attachment figures that is excessive for the person’s developmental stage. The 27 ASA-27 items cover how that fear shows up in adult life, including:
- Distress before leaving home, leaving someone close or going on a long trip
- Worry that people close to you will come to serious harm or leave you
- Difficulty sleeping alone, or sleeping better with voices, the TV or the lights on
- Headaches, stomachaches or nausea before work or other regular activities outside the home
- Panic attacks when separated from people close to you, or when thinking about it
- Concern that your relationships are too close or too intense
Every item asks about symptoms experienced as an adult over 18. The form does not record how long symptoms have lasted or how much they affect daily life. Capture both in your clinical notes. DSM-5-TR criteria call for adult symptoms that typically last six months or more and cause significant distress or impairment.
How to score the ASA-27
The patient rates each item from 0 to 3, and the 27 ratings add up to a raw score between 0 and 81. Higher scores indicate more severe adult separation anxiety symptoms. The scoring guide on the form sets out two cut-offs and three bands.
| Raw score | Band on the form | What it suggests |
|---|---|---|
| 0 to 15 | Low or no separation anxiety | Few symptoms, close to typical adult functioning. |
| 16 to 21 | Some separation anxiety | Mild to moderate signs. This high-sensitivity range catches almost every case but includes some false positives. |
| 22 or more | Probable adult separation anxiety disorder | Severe, widespread symptoms, such as avoidance, dependency and excessive concern for the safety of attachment figures. |
On the full 0 to 81 scale, the middle band spans only six points. One or two item ratings can move a patient across a cut-off. Use 22 as the primary cut-off for a probable disorder. Use 16 when missing a case would cost more than a few false positives, and follow every positive screen with an interview.
The form also has Percentile and Description fields. A percentile compares the score with a community sample, where 50 is the general-population average. The PDF has no percentile lookup table, so leave that field blank unless you have the published norms on hand.
Is there a separation anxiety test for children?
Yes, but it is not this download. The ASA-27 is an adult self-report measure for people over 18, and its items describe adult life, such as work, travel and relationships. Children and adolescents need an instrument validated for their age group, for example:
- The Screen for Child Anxiety Related Emotional Disorders (SCARED), with child and parent versions for ages 8 to 18 and a separation anxiety subscale
- The Spence Children’s Anxiety Scale (SCAS), a child self-report measure for ages 8 to 15 that includes separation anxiety items
- The NIH Toolbox parent-report Fear-Separation Anxiety measure for ages 3 to 7
Check the scoring rules and licensing terms of any of these against the publisher’s own materials before you use them.
How the ASA-27 differs from the Separation Anxiety Test (SAT)
The Separation Anxiety Test (SAT) is a separate projective measure, developed by Henry Hansburg and later adapted for young children by Klagsbrun and Bowlby. Children respond to pictures of separation scenes, and the clinician interprets their answers. Despite the shared name, the SAT is not what this download contains.
Your choice of instrument should match your setting, the patient’s age and the level of psychometric evidence you need. For adults, the ASA-27 gives you a short, scored screen with published cut-offs. If the question is attachment style rather than separation distress, the Adult Attachment Scale is the closer fit.
Where the ASA-27 fits in an intake workflow
Use the ASA-27 as a structured screen within a full assessment. The steps below fit a typical intake workflow.
- Confirm the patient is over 18, and choose an age-validated instrument for anyone younger.
- Ask the patient to rate all 27 items at intake or before the session.
- Add the ratings to get a raw score between 0 and 81, and write it on the form.
- Record the band in the Description field: low or none, some, or probable disorder.
- For scores of 16 or more, assess duration and functional impact against DSM-5-TR criteria in a clinical interview.
- Sign and date the form, add your license ID and file it in the patient record with a review date.
What the three-page form contains
The printable PDF runs to three pages. It holds the 27 ASA-27 items, each with a 0 to 3 rating. Below them sit raw score, percentile and description fields, plus the scoring guide with both cut-offs. The final section has name, license ID, signature and date fields for the reviewing clinician.
How Pabau supports anxiety screening in clinical workflows
Paper questionnaires tend to be completed in the waiting room, scored by hand and filed away from the rest of the notes. Pabau, the therapy practice management software we build, sends screening questionnaires through its digital forms before a session. You arrive with the responses already in hand.
Completed forms are saved to the patient record next to notes and intake forms, so you can compare ASA-27 scores across reviews. Store only what your data protection obligations allow, and review how you handle patient data under HIPAA or UK GDPR where they apply.
Send and store screening questionnaires digitally
Pabau’s digital forms send questionnaires like the ASA-27 to patients before their session and save completed responses to the patient record. Screening history stays in one place for every review.
Conclusion
The ASA-27 gives you a quick, scored read on adult separation anxiety, with cut-offs that tell you when a full assessment is warranted. Its value depends on using it with the group it was built for. Keep it for patients over 18, and use an age-validated child measure for anyone younger.
Treat a score of 22 or more as the trigger for a clinical interview. Duration and functional impact come from your assessment, since the form does not record them. Book a demo to see how Pabau sends, stores and tracks screening questionnaires for mental health practices.
Continue your research
Exploring fear of being left? Abandonment issues quiz gives you a free screen for abandonment fears in adult relationships.
Working on attachment patterns? Attachment theory worksheet helps patients reflect on attachment patterns in their relationships.
Is the anxiety mainly social? Social Interaction Anxiety Scale covers the 20 SIAS items and how to score them.
Screening for broader symptoms? Anxiety and depression test screens for anxiety and depression symptoms together.
Looking for a mental health workflow? Mental health EMR software covers the practice side of assessment records.
Frequently asked questions about separation anxiety tests
What is a separation anxiety test?
A separation anxiety test is a questionnaire that measures how strongly a person fears separation from attachment figures. The free PDF on this page is the ASA-27, a 27-item self-report screen for adults over 18.
Can I download a free separation anxiety test PDF?
Yes, the ASA-27 template is available as a free PDF download from this page. Use it as a screening aid alongside a full clinical interview.
Is there a separation anxiety test for adults?
Yes. The ASA-27 on this page was built for adults over 18, and a raw score of 22 or more suggests probable adult separation anxiety disorder. Confirm the result with a clinical interview.
Can the ASA-27 be used with children?
No. The ASA-27 is an adult measure for people over 18. For children and adolescents, use an age-validated instrument such as the SCARED, which has child and parent versions for ages 8 to 18.
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