Generalized Anxiety Disorder Screening Form

Generalized Anxiety Disorder 7-item (GAD-7) scale
This is a screening tool to help you determine whether you might have General Anxiety Disorder that needs professional attention. This screening tool is not designed to make a diagnosis but to be shared with Summit Behavioral Health mental health professional to inform further conversations about diagnosis and treatment. One of our providers will perform a free review of your form and contact you to discuss potential care options.
INSTRUCTIONS

1) Fill and submit shown form

2) Choose if you want to be contacted about your screening results

3) Select date/time for a brief meeting
Date *

Month Day Year
Date

Over the last 2 weeks, how often have you beenbothered by the following problems?

	Score
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Add the score and input below: *
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult
Do you consent to Summit BHP contacting you to discuss your results and care options? *
Select a date/time that works for you to discuss with Summit BHP staff:
If you answered Yes to the question above, please fill following section. We offer new patient appointments onsite and online within 1-3 days of submitting a request.
Name

First Name Last Name
Age
Gender
Phone Number

Area Code Phone Number
Summit Behavioral Health

2115 County Road D East, Suite C-100, Maplewood, MN 55109

Ph: 651-358-7020 www.SummitBHP.com
Should be Empty:

Generalized Anxiety Disorder 7-item (GAD-7) scale