Adult Mental Health Screeners - Northland Counseling Center

Thank you for choosing Northland Counseling Center, Inc! Please complete the below form as part of our intake process or for our annual update. Any missing information may cause a delay in services. Along with this form please ensure you are also filling out these additional forms:

if the page is blue, scroll to the bottom and click on desktop version. otherwise, the page will not submit.

Adult Pre-Intake Questionnaire
Adult Registration Form
Provider Supervision Form
Medicare Notice – please complete if you have Medicare as an insurance plan
Release of Information – Agencies & Providers

Please complete the form below and if you would like to learn more about why this information is important click here.

Adult Screeners

ACES GAD-7 GAIN-SS PHQ-9 WHODAS

Step 1 of 5

20%

Adverse Childhood Experience Questionnaire for Adults

Date

MM slash DD slash YYYY

Name(Required)

First Last

Email(Required)

Our relationships and experiences—even those in childhood—can affect our health and well-being. Difficult childhood experiences are very common. Please tell us whether you have had any of the experiences listed below, as they may be affecting your health today or may affect your health in the future. This information will help you and your provider better understand how to work together to support your health and well-being.

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18th birthday. Then, please add up the number of categories of ACEs you experienced and put the total number at the bottom.

Please check “YES” if the question applies to you. Please leave blank if the question does NOT apply to you.

If you are having a difficult time with answering any of these questions, check the YES below and skip to the next page. Thank you.

Yes

1. Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Yes

2. Did you lose a parent through divorce, abandonment, death, or other reason?

Yes

3. Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Yes

4. Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Yes

5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Yes

6. Did you live with anyone who went to jail or prison?

Yes

7. Did a parent or adult in your home ever swear at you, insult you, or put you down?

Yes

8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Yes

9. Did you feel that no one in your family loved you or thought you were special?

Yes

10. Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

Yes

Do you believe these experiences have affected your health?

Not much

Some

Alot

Name(Required)

First Last

Generalized Anxiety Disorder 7-Item (GAD-7) Form

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Not being able to stop or control worry(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Worry too much about different things(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Trouble relaxing(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Being so restless that it’s hard to sit still(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Becoming easily annoyed or irritable(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Feeling afraid as if something awful might happen(Required)

Not sure at all – 0

Several Days – 1

Over Half the Days – 2

Nearly Every Day – 3

Staff Only: Add the score for total score

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Please check the box next to the one that best describes the level of difficulty.(Required)

Not at all difficult

Somewhat difficult

Very Difficult

Extremely Difficult

Name(Required)

First Last

GAIN-SS

The following questions are about common psychological, behavioral and personal problems. These problems are considered significant when you have them for two or more 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.

IDSscr

After each of the following questions. Please tell us the last time you had this problem, if ever, by answering (circling) whether it was in the past month (4); 2-3 months ago (3); 4-12 months ago (2); 1 or more years ago (1); or never (0). Be sure to choose only one response. Please tell us when the last time you had significant problems.

Felt trapped, lonely, sad, blue, depressed or hopeless about the future(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Had sleep trouble, such as bad dreams, sleeping restlessly or falling asleep during the day(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Felt very anxious, nervous, tense, scared, panicked or like something bad was going to happen(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Became very distressed and upset when something reminded you of the past(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Thought about ending your life or committing suicide(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Saw or heard things that no one else could see or hear or felt that someone else could read or control your thoughts(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

EDSscr

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

Lied or conned to get things you wanted or to avoid having to do something(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Had a hard time paying attention at school, work, or home(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Had a hard time listening to instruction at school, work, or home(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Had a hard time waiting your turn(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Were a bully or threatened other people(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Started a physical fight with other people(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Tried to win back your gambling losses by going back another day(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

SDSscr

When was the last time that…

Used alcohol or other drugs weekly or more often….(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

You kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

You had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

CVSscr

When was the last time that…

Had a disagreement in which you pushed, grabbed, or shoved someone(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Took something from a store without paying for it(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Sold, distributed, or helped to make illegal drugs(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Drove a vehicle while under the influence of alcohol or illegal drugs(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Purposely damaged or destroyed property that did not belong to you(Required)

Past Month – 4

2-3 Months – 3

4-12 Months – 2

1+ year – 1

Never – 0

Do you have other significant psychological, behavioral or personal problems that you want treatment for or help with? If yes, please describe:

Name(Required)

First Last

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check the box next to the number that best describes how often you have been bothered by these problems.

Little interest or pleasure in doing things:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Feeling down, depressed, or hopeless:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Trouble falling or staying asleep, or sleeping too much:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Feeling tired or having little energy:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Poor appetite or overeating:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Feeling bad about yourself — or that you are a failure or have let yourself or your family down:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Trouble concentrating on things, such as reading the newspaper or watching television:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

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:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Thoughts that you would be better off dead or of hurting yourself in some way:(Required)

Not at all – 0

Several days – 1

More than half the days – 2

Nearly everyday – 3

Total Score: Adding the Score of your responses

How difficult have these problems been for you?(Required)

Not at all difficult

Somewhat difficult

Very Difficult

Extremely Difficult

Name(Required)

First Last

WHODAS

This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please check only one response.

Standing for long periods such as 30 minutes(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Taking care of your household responsibilities?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Learning a new task, for example, learning how to get to a new place?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

How much of a problem did you have joining in community activities (For example, festivities, religious or other activities) in the same way as anyone else can?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

How much have you been emotionally affected by your health problems?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Concentrating on doing something for ten minutes?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Walking a long distance such as mile (or equivalent)?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Washing your whole body?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Getting Dressed?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Dealing with people you do not know?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Maintaining Friendships?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Your day-to-day work?(Required)

0 None

1 Mild

2 Moderate

3 Severe

4 Extreme or cannot do

Overall, in the past 30 days, how many days were these difficulties present? (NUMBERS ONLY)(Required)

In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health conditions? (NUMBERS ONLY)(Required)

In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition? (NUMBERS ONLY)(Required)