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9
Questions
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1
Hide provider information?
YES
NO
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2
What is your name?
*
This field is required.
First Name
Last Name
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3
Which Cornerstone provider asked you to complete this assessment?
Diane Maciejewski
Kim Loveland
Lynn Martin
Michelle Schrubbe
Janelle Prince
Not Listed
Diane Maciejewski
Kim Loveland
Lynn Martin
Michelle Schrubbe
Janelle Prince
Not Listed
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4
Provider's Email
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5
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
(Move the blue slider left or right to answer)
Feeling nervous, anxious or on edge?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling nervous, anxious or on edge?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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6
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Not being able to stop or control worrying?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Not being able to stop or control worrying?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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7
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Worrying too much about different things?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Worrying too much about different things?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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8
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Trouble relaxing?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Trouble relaxing?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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9
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Being so restless that it is hard to sit still?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Being so restless that it is hard to sit still?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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10
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Becoming easily annoyed or irritable?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Becoming easily annoyed or irritable?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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11
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Feeling afraid as if something awful might happen?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling afraid as if something awful might happen?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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Submit
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12
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Not being able to stop or control worrying?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Worrying too much about different things?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Trouble relaxing?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Being so restless that it is hard to sit still?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Becoming easily annoyed or irritable?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Feeling afraid as if something awful might happen?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Feeling nervous, anxious or on edge?
Not being able to stop or control worrying?
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid as if something awful might happen?
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly every day
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly every day
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly every day
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly every day
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly every day
Row 6, Column 3
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13
Total Score
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