Free Mental Health Screening

Free Mental Health Screening

 

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Name
Have you ever received any form of mental health treatment?
Have you ever attempted to die by suicide?

Adverse Childhood Experiences Questionnaire (ACE-Q)

1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
3. Did an experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?
4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Were your parents ever separated or divorced?
7. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
10. Did a household member go to prison?

Generalized Anxiety Disorder 7-item Scale (GAD-7)

Over the past 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on edge
*Please select the answer that best reflects your experience using the following
2. Not being able to stop or control worrying
*Please select the answer that best reflects your experience using the following
3. Worrying too much about different things
*Please select the answer that best reflects your experience using the following
4. Trouble relaxing
*Please select the answer that best reflects your experience using the following
5. Being so restless that it's hard to sit still
*Please select the answer that best reflects your experience using the following
6. Becoming easily annoyed or irritable
*Please select the answer that best reflects your experience using the following
7. Feeling afraid as if something awful might happen
*Please select the answer that best reflects your experience using the following

Patient Health Questionnaire -9

Over the past 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things.
*Please select the answer that best reflects your experience using the following
2. Feeling down, depressed or hopeless
*Please select the answer that best reflects your experience using the following
3. Trouble falling asleep, staying asleep, or sleeping too much.
*Please select the answer that best reflects your experience using the following
4. Feeling tired or having little energy.
*Please select the answer that best reflects your experience using the following
5. Poor appetite or overeating.
*Please select the answer that best reflects your experience using the following
6. Feeling bad about yourself - or that you're a failure or have let yourself or your family down.
*Please select the answer that best reflects your experience using the following
7. Trouble concentrating on things, such as reading the newspaper or watching television.
*Please select the answer that best reflects your experience using the following
8. Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
*Please select the answer that best reflects your experience using the following
9. Thoughts that you would be better off dead or of hurting yourself in some way.
*Please select the answer that best reflects your experience using the following
If you have 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?
*Please select the answer that best reflects your experience using the following

The Mood Disorder Questionnaire

Has there ever been a period of time when you were not your usual self and...
1...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
*Please select the answer that best reflects your experience using the following
...you were so irritable that you shouted at people or started fights or arguments?
*Please select the answer that best reflects your experience using the following
...felt much more self-confident than usual?
*Please select the answer that best reflects your experience using the following
...you got much less sleep than usual and found you didn't really miss it?
*Please select the answer that best reflects your experience using the following
...you were much more talkative or spoke much faster than usual?
*Please select the answer that best reflects your experience using the following
...thoughts raced through your head or you couldn't slow your mind down?
*Please select the answer that best reflects your experience using the following
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
*Please select the answer that best reflects your experience using the following
...you had much more energy than usual?
*Please select the answer that best reflects your experience using the following
...you were much more active or did many more things than usual?
*Please select the answer that best reflects your experience using the following
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
*Please select the answer that best reflects your experience using the following
...you were much more interested in sex than usual?
*Please select the answer that best reflects your experience using the following
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
*Please select the answer that best reflects your experience using the following
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
*Please select the answer that best reflects your experience using the following
3. How much of a problem did any of these cause you - like being unable to work; having family, money, or legal problems; getting into arguments or fights? Please choose one response only.

PC-PTSD-5

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: • a serious accident or fire • a physical or sexual assault or abuse • an earthquake or flood • a war • seeing someone be killed or seriously injured • having a loved one die through homicide or suicide
Have you ever experienced this kind of event?

In the past month, have you...

1. had nightmares about the event(s) or thought about the event(s) when you did not want to?
*Please select the answer that best reflects your experience using the following
2. tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
*Please select the answer that best reflects your experience using the following
3. been constantly on guard, watchful, or easily startled?
*Please select the answer that best reflects your experience using the following
4. felt numb or detached from people, activities, or your surroundings?
*Please select the answer that best reflects your experience using the following
5. felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
*Please select the answer that best reflects your experience using the following

All questions are now complete.

A member of our team will contact you with your results within three business days.