"*" indicates required fields HiddenAssessment Date* MM slash DD slash YYYY Your Name* First Last Date of Birth* MM slash DD slash YYYY Your Race/Ethnicity*Please Choose...American Indian or Alaska NativeAsianBlack or African AmericanHispanic or Latino or Spanish OriginNative Hawaiian or Other Pacific IslanderWhitePrefer not to answerZIP Code*How many statements below apply to you?At any point since you were born...Your parents or guardians were separated or divorcedYou lived with someone who had a problem with drinking or using drugsYou lived with a household member who served time in jail or prisonSomeone pushed, grabbed, slapped or threw something at you OR you were hit so hard that you were injured or had marksA household member swore at, insulted, humiliated, or put you down in a way that scared you OR a household member acted in a way that made you afraid that you might be physically hurtTotal*Please enter a number from 0 to 5.How many statements below apply to you?At any point since you were born...You often felt unsupported, unloved and/or unprotectedMore than once, you went without food, clothing, a place to live, or had no one to protect youYou saw or heard household members hurt or threaten to hurt each otherSomeone touched your private parts or asked you to touch their private parts in a sexual wayYou lived with a household member who was depressed, mentally ill or attempted suicideTotal*Please enter a number from 0 to 5.How many statements below apply to you?At any point since you were born...You have been in foster careYou have experienced harassment or bullying at schoolYou have lived with a parent or guardian who diedYou have been separated from your primary caregiver through deportation or immigrationYou have had a serious medical procedure or life threatening illnessYou have often seen or heard violence in the neighborhood or in your school neighborhoodYou have been detained, arrested or incarceratedYou have often been treated badly because of race, sexual orientation, place of birth, disability or religionYou have experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)Total*Please enter a number from 0 to 9.HiddenACE-Q TotalYou’re doing great. Click or tap "Next" to continue to the next step in the form.Resilience Score1. I believe my mother loved me when I was little.* Definitely Not True Probably Not True Not Sure Probably True Definitely True2. I believe that my father loved me when I was little.* Definitely Not True Probably Not True Not Sure Probably True Definitely True3. When I was little, other people helped my parents take care of me and they seemed to love me.* Definitely Not True Probably Not True Not Sure Probably True Definitely True4. I’ve heard that when I was an infant, someone in my family enjoyed playing with me and I enjoyed it too.* Definitely Not True Probably Not True Not Sure Probably True Definitely True5. When I was a child, there were relatives in my family who helped me feel better when I was sad or worried.* Definitely Not True Probably Not True Not Sure Probably True Definitely True6. When I was a child, neighbors or my friends’ parents seemed to like me.* Definitely Not True Probably Not True Not Sure Probably True Definitely True7. When I was a child, teachers, coaches, youth leaders or ministers were there to help me.* Definitely Not True Probably Not True Not Sure Probably True Definitely True8. Someone in my family cared about how I was doing in school.* Definitely Not True Probably Not True Not Sure Probably True Definitely True9. My family, friends, neighbors and friends talked about making our lives better.* Definitely Not True Probably Not True Not Sure Probably True Definitely True10. We had rules in our house and were expected to keep them.* Definitely Not True Probably Not True Not Sure Probably True Definitely True11. When I felt really bad, I could almost always find someone I trusted to talk to.* Definitely Not True Probably Not True Not Sure Probably True Definitely True12. As a youth, people noticed that I was capable and could get things done.* Definitely Not True Probably Not True Not Sure Probably True Definitely True13. I was independent and a go-getter.* Definitely Not True Probably Not True Not Sure Probably True Definitely True14. I believe that life is what you make it.* Definitely Not True Probably Not True Not Sure Probably True Definitely True15. There are people I can count on now in my life.* Definitely Not True Probably Not True Not Sure Probably True Definitely TrueHiddenTotal Score - ResilienceWhat comments, questions or concerns do you have?I would be interested in: Behavioral Health Services Parent support groups Visiting home nurse programs Parenting classes OtherPlease tell us more.You’re doing great. Click or tap "Next" to continue to the next section. Brief PCL 5Your Name* First Last Your Race/EthnicityPlease Choose...American Indian or Alaska NativeAsianBlack or African AmericanHispanic or Latino or Spanish OriginNative Hawaiian or Other Pacific IslanderWhitePrefer not to answer1. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?* Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)2. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?* Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)3. Feeling distant or cut off from other people?* Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)4. Irritable behavior, angry outbursts, or acting aggressively?* Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)HiddenBrief PCL 5 - Total ScoreYou’re doing great. Click or tap "Next" to continue to the next section. GAD-7Over the last 2 weeks, how often have you been bothered by the following problems?1. Feeling nervous, anxious or on edge* Not at all Several Days More than half the days Nearly every day2. Not being able to stop or control worrying* Not at all Several Days More than half the days Nearly every day3. Worrying too much about different things* Not at all Several Days More than half the days Nearly every day4. Trouble relaxing* Not at all Several Days More than half the days Nearly every day5. Being so restless that it is hard to sit still* Not at all Several Days More than half the days Nearly every day6. Becoming easily annoyed or irritable* Not at all Several Days More than half the days Nearly every day7. Feeling afraid as if something awful might happen* Not at all Several Days More than half the days Nearly every dayHiddenTotal Score - GAD-7Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:a serious accident or firea physical or sexual assault or abusean earthquake or flooda warseeing someone be killed or seriously injuredhaving a loved one die through homicide or suicide.Have you ever experienced this kind of event?* Yes NoPlease answer the questions below. In the past month (August 21st, 2024 - September 20th, 2024), have you...1. had nightmares about the event(s) or thought about the event(s) when you did not want to?* Yes No2. 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)?* Yes No3. been constantly on guard, watchful, or easily startled?* Yes No4. felt numb or detached from people, activities, or your surroundings?* Yes No5. felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?* Yes NoHiddenPC-PTSD-5 Total ScorePHQ-9Name First Last ClinicianDate MM slash DD slash YYYY Instructions: Over the last two weeks, how often have you been bothered by any of the following problems?1.Little interest or pleasure in doing things?* Not at all Several Days More than half the days Nearly every day2.Feeling down, depressed or hopeless?* Not at all Several Days More than half the days Nearly every day3.Trouble falling or staying asleep, or sleeping too much?* Not at all Several Days More than half the days Nearly every day4.Feeling tired or having little energy?* Not at all Several Days More than half the days Nearly every day5.Poor appetite or overeating?* Not at all Several Days More than half the days Nearly every day6.Feeling bad about yourself – or that you are a failure, or have let yourself or your family down?* Not at all Several Days More than half the days Nearly every day7.Trouble concentrating on things, such as reading the newspaper or watching television?* Not at all Several Days More than half the days Nearly every day8.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?* Not at all Several Days More than half the days Nearly every day9.Thoughts that you would be better off dead or of hurting yourself in some way?* Not at all Several Days More than half the days Nearly every dayIf you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.HiddenPHQ-9 ScoreThank you!You have completed the screening. Please click the “Finish” button below to return to the home page. If you are completing this in the clinic, please return the tablet to your health care provider. 30329