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Intake Screenings Packet
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Today's Date
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Client's Name
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Date of Birth
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Are you completing this screening for an adult or a child/adolescent?
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Child/Adolescent
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5
PHQ-9 Screening
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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?
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?
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
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
Not at All
Several Days
More than 1/2 the days
Nearly Every Day
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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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Please be as accurate as possible
Not Difficult at All
Somewhat Difficult
Very Difficult
Extremely Difficult
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7
PCL-5 Screening
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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?
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?
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
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
Not at All
A Little Bit
Moderately
Quite A Bit
Extremely
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8
GAD-7 Screening
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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
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
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
Several Days
Over Half the Days
Nearly Every Day
Not at All
Several Days
Over Half the Days
Nearly Every Day
Not at All
Several Days
Over Half the Days
Nearly Every Day
Not at All
Several Days
Over Half the Days
Nearly Every Day
Not at All
Several Days
Over Half the Days
Nearly Every Day
Not at All
Several Days
Over Half the Days
Nearly Every Day
Not at All
Several Days
Over Half the Days
Nearly Every Day
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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?
*
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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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