Self Screening Tool

Once this form is completed you will be contacted by one of our Intake Specialist to get you connected to the appropriate service.

First Name Only *

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Phone Number *

1. Have you been consistently depressed or down, most of the day, nearly every day, for the past two weeks? *

• Yes
• No

2. In the past two weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time? *

• Yes
• No

3. Have you felt sad, low, or depressed most of the time for the last two years? *

• Yes
• No

4. In the past month, did you think that you would be better off dead or wish you were dead? *

• Yes
• No

5. Have you ever had a period of time when you were feeling up, hyper, or so full of energy or full of yourself that you got into trouble, or that other people thought you were not your usual self? Do not consider times when you were intoxicated on drugs or alcohol. *

• Yes
• No

6. Have you ever been so irritable, grouchy, or annoyed for several days, that you had arguments, had verbal or physical fights, or shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted, compared to other people, even when you thought you were right to act this way? *

• Yes
• No

7. Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable, or uneasy, even when most people would not feel that way? Did these intense feelings get to be their worst within ten minutes? *

• Yes
• No

8. Do you feel anxious or uneasy in places or situations where you might have the panic-like symptoms we just spoke about? Or do you feel anxious or uneasy in situations where help might not be available or escape might be difficult? Examples: ● being in a crowd, ● standing in a line, ● being alone away from home or alone at home, ● crossing a bridge, ● traveling in a bus, train, or car? *

• Yes
• No

9. In the past month, were you afraid or embarrassed when others were watching you or when you were the focus of attention? Were you afraid of being humiliated? Examples: ● speaking in public, ● eating in public or with others, ● writing while someone watches, ● being in social situations *

• Yes
• No

10. In the past month, have you been bothered by thoughts, impulses, or images that you couldn’t get rid of that were unwanted, distasteful, inappropriate, intrusive, or distressing? Examples: ● being afraid that you would act on some impulse that would be really shocking, ● worrying a lot about being dirty, contaminated, or having germs, ● worrying a lot about contaminating others, or that you would harm someone even though you didn’t want to, ● having fears or superstitions that you would be responsible for things going wrong, ● being obsessed with sexual thoughts, images, or impulses, ● hoarding or collecting lots of things, ● having religious obsessions. *

• Yes
• No

11. In the past month, did you do something repeatedly without being able to resist doing it? Examples: ● washing or cleaning excessively, ● counting or checking things over and over, ● repeating, collecting, or arranging things, ● other superstitious rituals. *

• Yes
• No

12. Have you ever experienced, witnessed, or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else? Examples: ● serious accidents, ● sexual or physical assault, ● terrorist attack, ● being held hostage, ● kidnapping, ● fire, ● discovering a body, ● sudden death of someone close to you, ● war, ● natural disaster. *

• Yes
• No

13. Have you re-experienced the awful event in a distressing way in the past month? Examples: ● dreams, ● intense recollections, ● flashbacks, ● physical reactions. *

• Yes
• No

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