Adolescent (11-17yo) Assessment/Evaluation

Adolescent Diagnostic Assessment / Evaluation

* Indicates required field

Client's Name *

First

Last

Client's DOB *

Date of Assessment *

Name & Title of Person Completing this Form *

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.

1. Numbness or tingling *

5. Fear of worst happening *

9. Terrified or afraid *

13. Shaky / unsteady *

17. Scared *

21. Hot / cold sweats *

2. Feeling hot *

6. Dizzy or lightheaded *

10. Nervous *

14. Fear of losing control *

18. Indigestion *

3. Wobbliness in legs *

7. Heart pounding / racing *

11. Feeling of choking *

15. Difficulty in breathing *

19. Faint / lightheaded *

4. Unable to relax *

8. Unsteady *

12. Hands trembling *

16. Fear of dying *

20. Face flushed *

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.

1. Sadness *

7. Self-Dislike *

2. Pessimism *

8. Self-Criticalness *

3. Past Failure *

4. Loss of Pleasure *

5. Guilty Feelings *

6. Punishment Feelings *

9. Suicidal Thoughts or Wishes *

10. Crying *

11. Agitation *

12. Loss of Interest *

17. Irritability *

13. Indecisiveness *

18. Changes in Appetite *

14. Worthlessness *

19. Concentration Difficulty *

15. Loss of Energy *

16. Changes in Sleeping Pattern *

Tiredness or Fatigue *

Loss of Interest in Sex *

OHIO - Y
Section I - Please rate the degree to which you have experienced the following problems in the past 30 days.

1. Arguing with others *

2. Getting into fights *

3. Yelling, swearing, or screaming at others *

4. Fits of anger *

5. Refusing to do things teachers or parents ask *

6. Causing trouble for no reaso *

7. Using drugs or alcohol *

8. Breaking rules or breaking the law (out past curfew, stealing)Select One *

9. Skipping school or classes *

10. Lying *

11. Can’t seem to sit still, having too much energy *

12. Hurting self (cutting or scratching self, taking pills)Select One *

13. Talking or thinking about death *

14. Feeling worthless or useless *

15. Feeling lonely and having no friends *

16. Feeling anxious or fearful *

17. Worrying that something bad is going to happen *

18. Feeling sad or depressed *

19. Nightmares *

20. Eating problems *

Section II

1a. Overall, how satisfied are you with your life right now? *

2a. How energetic and healthy do you feel right now? *

3a. How much stress or pressure is in your life right now? *

4a. How optimistic are you about the future? *

1b. How satisfied are you with the mental health services you have received so far?Select One *

2b. How much are you included in deciding your treatment? *

3b. Mental health workers involved in my case listen to me and know what I want. 1 *

4b. I have a lot of say about what happens in my treatment *

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.

1. Getting along with friends *

2. Getting along with family *

3. Dating or developing relationships with boyfriends or girlfriends *

4. Getting along with adults outside the family (teachers, principal) *

5. Keeping neat and clean, looking good *

6. Caring for health needs and keeping good health habits (taking medicines or brushing teeth) *

7. Controlling emotions and staying out of trouble *

8. Being motivated and finishing projects *

9. Participating in hobbies (baseball cards, coins, stamps, art) *

10. Participating in recreational activities (sports, swimming, bike riding) *

11. Completing household chores (cleaning room, other chores) *

12. Attending school and getting passing grades in school *

13. Learning skills that will be useful for future jobs *

14. Feeling good about self *

15. Thinking clearly and making good decisions *

16. Concentrating, paying attention, and completing taskz *

17. Earning money and learning how to use money wisely *

18. Doing things without supervision or restrictions *

19. Accepting responsibility for actions *

20. Ability to express feelings *

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.

Have you ever been in treatment for an alcohol problem? *

1 Drink = 12 oz Beer = 5 oz Wine = 1.5 oz liquor (1 shot)

1. How often do you have a drink containing alcohol? *

2. How many drinks containing alcohol do you have on a typical day when you are drinking? *

3. How often do you have four or more drinks on one occasion? *

4. How often during the last year have you found that you were not able to stop drinking once you had started? *

5. How often during the last year have you failed to do what was normally expected of you because of drinking? *

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? *

7. How often during the last year have you had a feeling of guilt or remorse after drinking? *

8. How often during the last year have you been unable to remember what happened the night before because of your drinking? *

9. Have you or someone else been injured because of your drinking? *

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? *

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:

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.

1. Repeated, disturbing memories, thoughts, or images of the stressful experience *

2. Repeated, disturbing dreams of the stressful experience. *

3. Suddenly acting or feeling as if the stressful experience were happening again (as if you were reliving it) *

4. Feeling very upset when something reminded you of the stressful event *

5. Having physical reactions (e.g. heart pounding, trouble breathing, or sweating) when something reminded you of the stressful experience *

6. Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it *

7. Avoiding activities or situations because they remind you of the stressful experience *

8. Trouble remembering important parts of the stressful event *

9. Loss of interest in activities that you used to enjoy? *

10. Felling distant or cut off from other people *

11. Feeling emotionally numb or being unable to have loving feelings for those close to you *

12. Feeling as if your future will somehow be cut short *

13. Trouble falling or staying asleep *

14. Feeling irritable or having angry outbursts *

15. Having difficulty concentrating *

16. Being "super alert" or watchful or on guard *

17. Feeling jumpy or easily startled *

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.

ADOLESCENT ASSESSMENT/EVALUATION complete for clients 11-17 yo