Monarch Therapeutic Services, LLC Transforms Distress Into Hope
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ADOLESCENT ASSESSMENT/EVALUATION   complete for clients 11-17 yo

    Adolescent Diagnostic Assessment / Evaluation
    BAI
    ​
    Below is a list of common symptoms of anxiety.  Please carefully read each item in the list.  Indicate how much you have been bothered by that symptom during the past 30 days, including today, by selecting the best-fit option from the drop down menus beneath each statement.
     
    BDI-II
    Please read each group of statements carefully, and the pick the one statement in each group that best describes the way you have been feeling during the past two weeks, including today.  If several statements in the group seem to apply equally well, select the highest number for that group.
    OHIO - Y
    ​
    Section I - Please rate the degree to which you have experienced the following problems in the past 30 days.
    Section II
    Section III - Below are some ways your problems might get in the way of your ability to do everyday activities. Read each item and circle the number that best describes your current situation. 
    DAST - 20
    The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months.  Carefully read each statement and decide if your answer is "Yes" or "No" then select the appropriate response.  
    In the statements "drug abuse" refers to (1) the use of prescribed or over the counter drugs in excess of the directions and (2) any non-medical use of drugs.  The various classes of drugs may include and are not limited to: cannabis (e.g. marijuana, hash), solvents, tranquilizers (e.g. Valium), barbiturates, cocaine, stimulants (e.g. speed), hallucinogens (e.g. LSD) or narcotics (e.g. heroin).  Remember that the questions do not include the use of alcoholic beverages.
    Please answer every question.  If you have difficulty with a statement, then choose the response that is mostly right. 
    AUDIT
    The following 10 questions concern information about your potential involvement with alcoholic beverages during the past 12 months.  Carefully read each statement then select the appropriate response from the drop down menu.  
    Please answer every question.  If you have difficulty with a statement, then choose the response that is mostly right. 
    1 Drink = 12 oz Beer = 5 oz Wine = 1.5 oz liquor (1 shot)  
    C-SSRS
    The following questions concern information about your potential risk of self-harm.  Your honest answers to these questions will help us better be able to help you. In the past 30 days:
    If YES to 2, answer questions 3, 4, 5, and 6.  If NO to 2, go directly to question 6.
    PCL
    Below is a list of problems and complaints that people sometimes have in response to stressful life experiences.  Please read each one carefully, then make a selection from the drop down menu to indicate how much you have been bothered by the problem in the past month.
    Thank you for taking time to provide this important information that will help us to provide you with the best treatment, referrals, and/or recommendations to address your concerns.  All items require a response; please review your responses for completeness and accuracy then click the submit button below. 

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