Sandstone Psychology Mental Health Screening 
Short screener 
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First Name *
Last Name *
Phone Number *
City
*Payson, Spanish Fork, Salem, etc.
E-mail *
Sex
Race/Ethnicity
Have you ever received any form of mental health treatment?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
 *
Have you ever taken medication for psychological problems?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
 *
Have you ever attempted suicide?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
 *
Patient Health Questionnaire -9
Over the past 2 weeks, how often have you been bothered by any of the following problems?
1.  Little interest or pleasure in doing things.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or  3 - Nearly every day
 *
2.  Feeling down, depressed or hopeless

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
3.  Trouble falling asleep, staying asleep, or sleeping too much.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
4.  Feeling tired or having little energy.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
5.  Poor appetite or overeating.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
6.  Feeling bad about yourself - or that you're a failure or have let yourself or your family down.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or  3 - Nearly every day
 *
7.  Trouble concentrating on things, such as reading the newspaper or watching television.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
8.  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.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
9. Thoughts that you would be better off dead or of hurting yourself in some way.

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
 *
If you have 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? *
Generalized Anxiety Disorder 7-item Scale (GAD-7)
Over the past 2 weeks, how often have you been bothered by any of the following problems?
1.  Feeling nervous, anxious, or on edge

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
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2.  Not being able to stop or control worrying

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
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3.  Worrying too much about different things

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
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4. Trouble relaxing

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
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5.  Being so restless that it's hard to sit still

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
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6.  Becoming easily annoyed or irritable

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, 3 - Nearly every day
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7.  Feeling afraid as if something awful might happen

*Please select the answer that best reflects your experience using the following:
 0 - Not at all, 1 - Several days, 2 - More than half the days, or 3 - Nearly every day
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The Mood Disorder Questionnaire
Has there ever been a period of time when you were not your usual self and...
1...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you were so irritable that you shouted at people or started fights or arguments?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...felt much more self-confident than usual?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you got much less sleep than usual and found you didn't really miss it?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you were much more talkative or spoke much faster than usual?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...thoughts raced through your head or you couldn't slow your mind down?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you were so easily distracted by things around you that you had trouble concentrating or staying on track?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you had much more energy than usual?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you were much more active or did many more things than usual?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you were much more interested in sex than usual?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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3. How much of a problem did any of these cause you - like being unable to work; having family, money, or legal problems; getting into arguments or fights? Please choose one response only.
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PC-PTSD-5
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
• a serious accident or fire
• a physical or sexual assault or abuse
• an earthquake or flood
• a war
• seeing someone be killed or seriously injured
• having a loved one die through homicide or suicide

Have you ever experienced this kind of event?
 *
In the past month, have you...
1. had nightmares about the event(s) or thought about the event(s) when you did not want to?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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2. tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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3. been constantly on guard, watchful, or easily startled?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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4. felt numb or detached from people, activities, or your surroundings? 

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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5. felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

*Please select the answer that best reflects your experience using the following:
1- Yes or 0- No
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You're done! 
One of our staff will contact you with your results within two business days.
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