GAIN Short Screener

Name*

First NameLast Name

The following questions are about common psychological behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can't go on.

After each of the following questions, please tell us the last time, if ever, you had the problem by answering whether it was in the past month, 2 to 3 months ago, 4 to 12 months ago, 1 or more years ago, or never.

IDScr 1. When was the last time that you had significant problems with...*

	Past month (4)	2 to 3 months ago (3)	4 to 12 months ago (2)	1+ years ago (1)	Never (0)
a) feeling very trapped. lonely, sad. blue, depressed, or hopeless about the future?
b) sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?
c) feeling very anxious. nervous. tense. scared, panicked, or like something bad was going to happen?
d) becoming very distressed and upset when something reminded you of the past?
e) thinking about ending your life or committing suicide?

Office Use ID Scr 1.

EDScr 2. When was the last time that you did the following things two or more times?*

	Past month (4)	2 to 3 months ago (3)	4 to 12 months ago (2)	1+ years ago (1)	Never (0)
a) Lied or conned to get things you wanted or to avoid having to do something
b) Had a hard time paying attention at school, work, or home
c) Had a hard time listening to instructions at school, work, or home
d) Were a bully or threatened other people
e) Started physical fights with other people

Office Use EDScr 2.

IDScr 3. When was the last time that...*

	Past month (4)	2 to 3 months ago (3)	4 to 12 months ago (2)	1+ years ago (1)	Never (0)
a) you used alcohol or other drugs weekly or more often?
b) you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs. or recovering from the effects of alcohol or other drugs (e.g., feeling sick)?
c) you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?
d) your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events?
e) you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?

Office Use SDScr 3.

IDScr 4. When was the last time that you...*

	Past month (4)	2 to 3 months ago (3)	4 to 12 months ago (2)	1+ years ago (1)	Never (0)
a) had a disagreement in which you pushed, grabbed, or shoved someone?
b) took something from a store without paying for it?
c) sold, distributed, or helped to make illegal drugs?
d) drove a vehicle while under the influence of alcohol or illegal drugs?
e) purposely damaged or destroyed property that did not belong to you?

Office Use CVScr 4.

Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? *

YesNo

If yes, please describe.

What is your gender? (If other, describe below)*

MaleFemaleOther

How old are you today?*

How long this form took to complete:

Evergreen Youth & Family Services