GAIN Short Screener (GAIN-SS)

  • GAIN Short Screener (GAIN-SS)

    Version [GVER]: GSS 2.0.1

  • This Form containing the Gain short Screener is to be filled out by the Minor Client (middle school aged or older).

     

     

    Parent/ Guardian Please DO NOT fill out these forms for your Child

     

    We recognized that it may seem unusual for some of the questions to be asked of your minor child. Please know that we ask every child of middle school age or higher to complete these forms so that we can provide the best, most comprehensive evaluation for your child.

    Thank you for your cooperation.

  • What is today's date?*
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  • The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two ormore 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 that you had the problem, if ever, by answering, “In the past month” (3), “2-12 months ago” (2), “1 or more years ago” (1), or “Never” (0).

  • IDScr

     

    1. When was the last time that you had significant problems…

  • A. with feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?*
  • B. with sleeping, such as bad dreams, sleeping restlessly, or falling asleep during the day?*
  • C. with feeling very anxious, nervous, tense, fearful, scared, panicked,or like something bad was going to happen?*
  • D. with becoming very distressed and upset when somethingreminded you of the past?*
  • E. with thinking about ending your life or committing suicide?*

  • EDScr

     

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

  • 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 fights with other people?*

  • SDScr

     

    3. When was the last time that…

  • A. You used alcohol or drugs weekly?*
  • B. You spent a lot of time either getting alcohol or drugs, using alcohol ordrugs, or feeling the effects of alcohol or drugs?*
  • C. You kept using alcohol or drugs even though it was causing socialproblems, leading to fights, or getting you into trouble with other people?*
  • D. Your use of alcohol or drugs caused you to give up, reduce or haveproblems at important activities at work, school, home, or social events?*
  • E. You had withdrawal problems from alcohol or drugs like shaking hands,throwing up, having trouble sitting still or sleeping, or that you used anyalcohol or drugs to stop being sick or avoid withdrawal problems?*

  • CVScr

    4) When was the last time that you...

  • 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?*
  • 5. Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? (If yes, please describe below)*
  • 6. What is your gender? (If other, please describe below)*

  • For Staff Use Only

  • This instrument is copyright © 2005 Chestnut Health Systems. Use of this measure is permitted for anyone who holds a GAIN license or is requesting a new one. For more information on the measure or licensure, please see www.chestnut.org/li/gain, e-mail gainsupport@chestnut.org, or contact Joan Unsicker at 309-827-6026 ext. 8-3413 or junsicker@chestnut.org.

     

    GSS 2.0.1.doc     12/7/05

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