Today's Date* MM slash DD slash YYYY Client's Name* First Last Client's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formEmail GAIN-Short Screener (GAIN-SS)The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can't go on.1a. When was the last time that you had significant problems with feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 1b. When was the last time that you had significant problems with sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 1c. When was the last time that you had significant problems with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 1d. When was the last time that you had significant problems with becoming very distressed and upset when something reminded you of the past?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 1e. When was the last time that you had significant problems with thinking about ending your life or committing suicide?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never This field is hidden when viewing the formIDScrNumber of 2s and 3s2a. When was the last time that you did the following thing two or more times?*Lied or conned to get things you wanted to avoid having to do something Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 2b. When was the last time that you did the following thing two or more times?*Had a hard time paying attention at school, work, or home Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 2c. When was the last time that you did the following thing two or more times?*Had a hard time listening to instructions at school, work, or home Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 2d. When was the last time that you did the following thing two or more times?*Were a bully or threatened other people Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 2e. When was the last time that you did the following thing two or more times?*Started physical fights with other people Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never This field is hidden when viewing the formEDScrNumber of 2s and 3s3a. When was the last time that you used alcohol or other drugs weekly or more often?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 3b. When was the last time that you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 3c. When was the last time that 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?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 3d. When was the last time that your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home, or social events?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 3e. When was the last time that you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never This field is hidden when viewing the formSDScrNumber of 2s and 3s4a. When was the last time that you had a disagreement in which you pushed, grabbed, or shoved someone?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 4b. When was the last time that you took something from a store without paying for it?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 4c. When was the last time that you sold, distributed, or helped to make illegal drugs?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 4d. When was the last time that you drove a vehicle while under the influence of alcohol or illegal drugs?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never 4e. When was the last time that you purposely damaged or destroyed property that did not belong to you?* Within the past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never This field is hidden when viewing the formCVScrNumber of 2s and 3s5. Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with?* Yes No Please describe other significant psychological, behavioral, or personal problems that you want treatment for or help with.*6. What is your gender?* Male Female 7. How old are you today?*
