GAD 11-17

Please complete this form if you are between the ages of 11-17. Thank you for choosing Northland Counseling Center!

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GAD 11-17

Today's Date*
MM slash DD slash YYYY
Name*
First Middle Last
Email
Who will the client see for today's appointment*
- Dr. Kefalas
- Angela Pellerito
- Other
Date of your appointment*
MM slash DD slash YYYY
Instructions
The 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 Only
Staff: You will have to manually score questions
Total/Partial Raw Score:
Prorated Total Raw Score: (if 1-2 items left unanswered)
Average Total Score:

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Friday: 8:00am to 12:00pm

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Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.

GAD 11-17

GAD 11-17

Instructions

Staff Use Only

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Complete Continuum of Care