GAIN-Short Screener (Adults)

What is your name?*

First NameMiddle NameLast Name

What is today's date*

Date

DOB*

Date

Therapist you’re scheduled with*

First NameLast Name

The following questions are about common psychological, behavioral or
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.

After each of the following statements, please tell us the last time you had this
problem, if ever, by responding (circling) in the past month (3), 2-12 months
ago (2), 1 or more years ago (1), or never (0)

IDScr 1. When was the last time you had significant problems…

a. with feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?

3210

b. with sleeping, such as bad dreams, sleeping restlessly or falling asleep during the day?

3210

c. with feeling very anxious, nervous, tense, fearful, scared, panicked or like something bad was going to happen?

3210

d. when something reminded you of the past, and you became very distressed and upset?

3210

e. with thinking about ending your life or committing suicide?

3210

EDScr 2. When was the last time you did the following things two or more times?

a. Lied or conned to get things you wanted or to avoid having to do something?

3210

b. Had a hard time paying attention at school, work or home?

3210

c. Had a hard time listening to instructions at school, work or home?

3210

d. Were a bully or threatened other people?

3210

e. Started fights with other people?

3210

SDScr 3. When was the last time...

a. you used alcohol or drugs weekly?

3210

b. you spent a lot of time either getting alcohol or drugs, using alcohol or drugs, or feeling the effects of alcohol or drugs (high, sick)?

3210

c. you kept using alcohol or drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?

3210

d. your use of alcohol or drugs caused you to give up, reduce or have problems at important activities at work, school, home or social events?

3210

e. you had withdrawal problems from alcohol or drugs like shaking hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or drugs to stop being sick or avoid withdrawal problems?

3210

CVScr 4. When was the last time you...

a. had a disagreement in which you pushed, grabbed, or shoved someone?

3210

b. took something from a store without paying for it?

3210

c. sold, distributed or helped to make illegal drugs?

3210

d. drove a vehicle while under the influence of alcohol or illegal drugs?

3210

e. purposely damaged or destroyed property that did not belong to you?

3210

5. Do you have other significant psychological, behavioral or personal problems you want treatment for or help with?

YesNo

(if yes, please describe below)

6. What is your gender?

MaleFemaleOther

If Other, please describe below

7. How old are you today?

Years old

Site ID:      Site Name v.
Staff ID:      Staff Name v.
Client ID:      Comment v.
Mode: 1-Administered by staff 2-Administered by other 3-Self Administered

Number of 2&3s: IDScr

Number of 2&3s: EDScr:

Number of 2&3s: SDScr:

Number of 2&3s: CVScr:

Number of 2&3s: TDScr:

13. Referral:

MHSAANGOther

14. Referral Code:

15. Referral Comments:

This instrument is copyrighted by Chestnut Health Systems 2005. Use of this measure is allowed for anyone with an existing GAIN license or who is requesting a new one. For more information on the measure or licensure, please see www.chestnut.org/li/gain or e-mail gainsupport@chestnut.org or contact Joan Unsicker at 309-827-6026, ext. 8-3413, junsicker@chestnut.org.

GAIN-Short Screener (Adults)

For Staff Use Only