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Intake Screenings Packet
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1
Today's Date
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Year
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2
Client's First & Last Name
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First and Last Name
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3
Date of Birth
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Date
Month
Day
Year
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4
Are you completing this screening for an adult or a child/adolescent?
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Adult
Child/Adolescent
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5
PHQ-9 Screening
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This field is required.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
1. Little interest or pleasure in doing things?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2. Feeling down, depressed, or hopeless?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3. Trouble falling or staying asleep, or sleeping too much?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4. Feeling tired or having little energy?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5. Poor appetite or overeating?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
6. Feeling bad about yourself, that you are a failure, or have let yourself or your family down?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
7. Trouble concentrating on things, such as reading the newspaper or watching television?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
8. Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you've been moving around a lot more than usual?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
9. Thoughts that you would be better off dead, or hurting yourself in some way?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
3. Trouble falling or staying asleep, or sleeping too much?
4. Feeling tired or having little energy?
5. Poor appetite or overeating?
6. Feeling bad about yourself, that you are a failure, or have let yourself or your family down?
7. Trouble concentrating on things, such as reading the newspaper or watching television?
8. Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you've been moving around a lot more than usual?
9. Thoughts that you would be better off dead, or hurting yourself in some way?
Not at All
Row 0, Column 0
Several Days
Row 0, Column 1
More than 1/2 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 1/2 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 1/2 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 1/2 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 1/2 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 1/2 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 1/2 the days
Row 6, Column 2
Nearly Every Day
Row 6, Column 3
Not at All
Row 7, Column 0
Several Days
Row 7, Column 1
More than 1/2 the days
Row 7, Column 2
Nearly Every Day
Row 7, Column 3
Not at All
Row 8, Column 0
Several Days
Row 8, Column 1
More than 1/2 the days
Row 8, Column 2
Nearly Every Day
Row 8, Column 3
1
of 9
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6
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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This field is required.
Please be as accurate as possible
Not Difficult at All
Somewhat Difficult
Very Difficult
Extremely Difficult
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7
PCL-5 Screening
*
This field is required.
Instructions:
Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the answers, to indicate how much you have been bothered by that problem in the past month.
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
1. Repeated, disturbing, and unwanted memories of the stressful experience?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
2. Repeated, disturbing dreams of the stressful experience?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
4. Feeling very upset when something reminded you of the stressful experience?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
8. Trouble remembering important parts of the stressful experience?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
10. Blaming yourself or someone else for the stressful experience or what happened after it?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
12. Loss of interest in activities that you used to enjoy?
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
13. Feeling distant or cut off from other people?
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
15. Irritable behavior, angry outbursts, or acting aggressively?
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
16. Taking too many risks or doing things that could cause you harm?
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
17. Being “superalert” or watchful or on guard?
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
18. Feeling jumpy or easily startled?
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
19. Having difficulty concentrating?
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
20. Trouble falling or staying asleep?
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being “superalert” or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?
Not at All
Row 0, Column 0
A Little Bit
Row 0, Column 1
Moderately
Row 0, Column 2
Quite A Bit
Row 0, Column 3
Extremely
Row 0, Column 4
Not at All
Row 1, Column 0
A Little Bit
Row 1, Column 1
Moderately
Row 1, Column 2
Quite A Bit
Row 1, Column 3
Extremely
Row 1, Column 4
Not at All
Row 2, Column 0
A Little Bit
Row 2, Column 1
Moderately
Row 2, Column 2
Quite A Bit
Row 2, Column 3
Extremely
Row 2, Column 4
Not at All
Row 3, Column 0
A Little Bit
Row 3, Column 1
Moderately
Row 3, Column 2
Quite A Bit
Row 3, Column 3
Extremely
Row 3, Column 4
Not at All
Row 4, Column 0
A Little Bit
Row 4, Column 1
Moderately
Row 4, Column 2
Quite A Bit
Row 4, Column 3
Extremely
Row 4, Column 4
Not at All
Row 5, Column 0
A Little Bit
Row 5, Column 1
Moderately
Row 5, Column 2
Quite A Bit
Row 5, Column 3
Extremely
Row 5, Column 4
Not at All
Row 6, Column 0
A Little Bit
Row 6, Column 1
Moderately
Row 6, Column 2
Quite A Bit
Row 6, Column 3
Extremely
Row 6, Column 4
Not at All
Row 7, Column 0
A Little Bit
Row 7, Column 1
Moderately
Row 7, Column 2
Quite A Bit
Row 7, Column 3
Extremely
Row 7, Column 4
Not at All
Row 8, Column 0
A Little Bit
Row 8, Column 1
Moderately
Row 8, Column 2
Quite A Bit
Row 8, Column 3
Extremely
Row 8, Column 4
Not at All
Row 9, Column 0
A Little Bit
Row 9, Column 1
Moderately
Row 9, Column 2
Quite A Bit
Row 9, Column 3
Extremely
Row 9, Column 4
Not at All
Row 10, Column 0
A Little Bit
Row 10, Column 1
Moderately
Row 10, Column 2
Quite A Bit
Row 10, Column 3
Extremely
Row 10, Column 4
Not at All
Row 11, Column 0
A Little Bit
Row 11, Column 1
Moderately
Row 11, Column 2
Quite A Bit
Row 11, Column 3
Extremely
Row 11, Column 4
Not at All
Row 12, Column 0
A Little Bit
Row 12, Column 1
Moderately
Row 12, Column 2
Quite A Bit
Row 12, Column 3
Extremely
Row 12, Column 4
Not at All
Row 13, Column 0
A Little Bit
Row 13, Column 1
Moderately
Row 13, Column 2
Quite A Bit
Row 13, Column 3
Extremely
Row 13, Column 4
Not at All
Row 14, Column 0
A Little Bit
Row 14, Column 1
Moderately
Row 14, Column 2
Quite A Bit
Row 14, Column 3
Extremely
Row 14, Column 4
Not at All
Row 15, Column 0
A Little Bit
Row 15, Column 1
Moderately
Row 15, Column 2
Quite A Bit
Row 15, Column 3
Extremely
Row 15, Column 4
Not at All
Row 16, Column 0
A Little Bit
Row 16, Column 1
Moderately
Row 16, Column 2
Quite A Bit
Row 16, Column 3
Extremely
Row 16, Column 4
Not at All
Row 17, Column 0
A Little Bit
Row 17, Column 1
Moderately
Row 17, Column 2
Quite A Bit
Row 17, Column 3
Extremely
Row 17, Column 4
Not at All
Row 18, Column 0
A Little Bit
Row 18, Column 1
Moderately
Row 18, Column 2
Quite A Bit
Row 18, Column 3
Extremely
Row 18, Column 4
Not at All
Row 19, Column 0
A Little Bit
Row 19, Column 1
Moderately
Row 19, Column 2
Quite A Bit
Row 19, Column 3
Extremely
Row 19, Column 4
1
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8
GAD-7 Screening
*
This field is required.
Over the last 2-weeks, how often have you been bothered by the following?
Not at All
Several Days
Over Half the Days
Nearly Every Day
1. Feeling nervous, anxious, or on edge
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2. Not being able to stop or control worrying
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3. Worrying too much about different things
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4. Trouble relaxing
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5. Being so restless that it's hard to sit still
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
6. Becoming easily annoyed or irritable
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
7. Feeling afraid as if something awful might happen
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Not at All
Row 0, Column 0
Several Days
Row 0, Column 1
Over 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
Over 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
Over 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
Over 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
Over 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
Over 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
Over Half the Days
Row 6, Column 2
Nearly Every Day
Row 6, Column 3
1
of 7
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9
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
This field is required.
Please be as accurate as possible
Not Difficult at All
Somewhat Difficult
Very Difficult
Extremely Difficult
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10
PHQ-9 (Depression) Results
Minimal Depression: 00-04 Mild Depression: 05-09 Moderate Depression: 10-14 Moderately Severe Depression: 15-19 Severe Depression: 20-27
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11
PCL-5 (Trauma) Results
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12
GAD-7 (Anxiety) Results
Minimal Anxiety: 00-04 Mild Anxiety: 05-10 Moderate Anxiety: 10-14 Severe Anxiety: 15-21
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