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.

Clinician:*
Please select the clinician from the card given to you by the front desk:
What is your full name?*

First NameLast Name
What is today's date?*

MonthDayYear
Date
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?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
B. with sleeping, such as bad dreams, sleeping restlessly, or falling asleep during the day?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
C. with feeling very anxious, nervous, tense, fearful, scared, panicked,or like something bad was going to happen?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
D. with becoming very distressed and upset when somethingreminded you of the past?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
E. with thinking about ending your life or committing suicide?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
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?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
B. Had a hard time paying attention at school, work, or home?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
C. Had a hard time listening to instructions at school, work, or home?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
D. Were a bully or threatened other people?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
E. Started fights with other people?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
SDScr

3. When was the last time that…
A. You used alcohol or drugs weekly?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
B. You spent a lot of time either getting alcohol or drugs, using alcohol ordrugs, or feeling the effects of alcohol or drugs?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
C. You kept using alcohol or drugs even though it was causing socialproblems, leading to fights, or getting you into trouble with other people?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
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?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
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?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
CVScr

4) When was the last time that you...
A. Had a disagreement in which you pushed, grabbed, or shoved someone?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
B. Took something from a store without paying for it?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
C. Sold, distributed, or helped to make illegal drugs?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
D. Drove a vehicle while under the influence of alcohol or illegal drugs?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
E. Purposely damaged or destroyed property that did not belong to you?*

3) Past Month2) 2-12 Months Ago1) 1+ Year agoNever
5. Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? (If yes, please describe below)*

1) Yes0) No
v1.
v2.
v3.
6. What is your gender? (If other, please describe below)*

1) Male2) Female99) Other
v1.
7. How old are you today? (In years)*
For Staff Use Only
IDSscr - Number of 2s and 3s:
EDScr - Number of 2s and 3s:
SDScr - Number of 2s and 3s:
CVScr - Number of 2s and 3s:
Total Number of 2s and 3s:
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
Should be Empty: