Ages 11-17 GAIN-SS

Thank you for choosing Northland Counseling Center! Please take a few minutes to complete the below form. When complete please complete the Minor Registration Ages 11-17, Ages 11-17 Health Questionnaire (HQ), SDQ-Parent Form, SDQ-Teen Form, Authorization to treat a minor, GAD 7 & PHQ-A.

GAIN-SS Ages 11 – 17

Date
MM slash DD slash YYYY
Email
Name
First Last
GAIN-SS
Please check the box next to the number that tells us how long ago you experienced each of the following…
IDSscr
Felt trapped, lonely, sad, depressed, blue, or hopeless about the future
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Had sleep trouble, such as bad dreams, sleeping restlessly or falling asleep during the day
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Felt very anxious, nervous, tense, scared, panicked or like something bad was going to happen
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Became very distressed and upset when something reminded you of the past
- Past Month – 4
- 2-3 Months- 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Thought about ending your life or committing suicide
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Saw or heard things that no one else could see or hear or felt that someone else could read or control your thoughts
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
EDSscr
Lied or conned to get things you wanted or to avoid having to do something
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Had a hard time paying attention at school, work, or home
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Had a hard time listening to instruction at school, work, or home
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Had a hard time waiting your turn
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Were a bully or threatened other people
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Started a physical fight with other people
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Tried to win back your gambling losses by going back another day
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
SDSscr
Used alcohol or other drugs weekly or more often…..
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
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
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
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
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
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
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
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
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
CVSscr
Had a disagreement in which you pushed, grabbed, or shoved someone
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Took something from a store without paying for it
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Sold, distributed, or helped to make illegal drugs
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Drove a vehicle while under the influence of alcohol or illegal drugs
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Purposely damaged or destroyed property that did not belong to you
- Past Month – 4
- 2-3 Months – 3
- 4-12 Months – 2
- 1+ year – 1
- Never
Do you have other significant psychological, behavioral or personal problems that you want treatment for or help with? If yes, please describe:
Consent
By clicking this box, I agree that that the information is true and accurate to the best of my knowledge.

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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.

Ages 11-17 GAIN-SS

GAIN-SS Ages 11 – 17

GAIN-SS

IDSscr

EDSscr

SDSscr

CVSscr

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Complete Continuum of Care