Please complete this form if you are between the ages of 11-17. Thank you for choosing Northland Counseling Center! GAD 11-17 Today's Date* Date Format: MM slash DD slash YYYY Name of Client* First Middle Last Who will the client see for today's appointment*Dr. KefalasAngela PelleritoOtherDate of your appointment* Date Format: MM slash DD slash YYYY InstructionsThe following questions ask about thoughts, feelings and behaviors, often tied to concerns about family, health, finances, school, and work. Please respond to each of them by marking one checkbox per row.felt moments of sudden terror, fear, or fright*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)felt anxious, worried or nervous*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)had thoughts of bad things happening, such as family tragedy, ill health, loss of job, or accidents*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)felt a racing heart, sweaty, trouble breathing, faint or shaky*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)avoided, or did not approach or enter, situations about which I worry*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)left situations early or participated only minimally due to worries*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)spent lots of time making decisions, putting off making decisions, or preparing for situations, due to worries*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)sought reassurance from others due to worries*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)needed help to cope with anxiety (e.g., alcohol or medication, superstitious objects, or other people)*Never (0)Occasionally (1)Half of the time (2)Most of the time (3)All of the time (4)Staff Use OnlyStaff: You will have to manually score questionsTotal/Partial Raw Score:Prorated Total Raw Score: (if 1-2 items left unanswered)Average Total Score:If you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.
