Assessment Questionnaire | Vive Adolescent Care

Your first name

Your last name

Email address

Phone number

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In the past 2 weeks: Has (person being assessed) expressed feelings of guilt, shame, extreme sadness, loneliness, fatigue/lethargy, or hopelessness?

No, not at all

Yes, several days (in the past 2 weeks)

Yes, more than half the days (in the past 2 weeks)

Yes, almost every day (in the past 2 weeks)

In the past 72 hours: Has (person being assessed) shown thoughts/behavior of harming themselves or of contemplating suicide?

No, and has NOT shown this in the past 2 weeks

No, but HAS shown this in the past 2 weeks

No, but HAS shown thoughts/behavior of not wanting to be alive or wished they were dead

Yes, HAS shown thoughts/behavior in the past 72 hours, but not currently

Yes, and IS CURRENTLY showing these thoughts or behaviors!

In the past 72 hours: Has (person being assessed) shown thoughts or behaviors toward the harming of others?

No, and has NOT shown this in the past 2 weeks

No, but HAS shown this in the past 2 weeks

Yes, HAS shown thoughts/behaviors in the past 72 hours, but not currently

Yes, and IS CURRENTLY showing these thoughts or behaviors!

In the past 72 hours: Has (person being assessed) struggled to control their temper to the point of rage, e.g., hurting others, property destruction, hurting animals, running away, etc.?

No, and has NOT shown this in the past 2 weeks

No, but HAS shown this in the past 2 weeks

Yes, HAS shown thoughts/behaviors in the past 72 hours, but not currently

Yes, and IS CURRENTLY showing these thoughts or behaviors

In the past 2 weeks: Has (person being assessed) expressed feelings of anxiety, irritability or agitation, paranoid thoughts, or panic episodes (panic attacks)?

No, not at all

Yes, several days (in the past 2 weeks)

Yes, more than half the days (in the past 2 weeks)

Yes, almost every day (in the past 2 weeks)

Do these experiences/thoughts prevent (person being assessed) from attending school, work, therapy, or other social functions that need to be completed?

No, not at all

Yes, several days (in the past 2 weeks)

Yes, more than half the days (in the past 2 weeks)

Yes, almost every day (in the past 2 weeks)

Does (person being assessed) experience any difficulties falling or staying asleep?

No difficulties with sleep

Yes, this person wakes up often but can fall back asleep

Yes, this person cannot fall asleep for more than an hour

Yes, this person wakes up often due to nightmares/panic episodes

Yes, this person sometimes/often doesn't sleep at all

Yes, this person sleeps less than 4 hours per night

In the past 72 hours: Has (person being assessed) expressed feelings of being watched, a fear that someone is constantly out to get them, or other irrational, paranoid thoughts, e.g., phone being tapped, camera being hacked, on a government watch list, etc.?

No, and has NOT expressed this in the past 2 weeks

No, but HAS expressed this in the past 2 weeks

Yes, HAS expressed thoughts/behaviors in the past 72 hours, but not currently

Yes, and IS CURRENTLY expressing these thoughts or behaviors

In the past 72 hours: Has (person being assessed) expressed the experience of hearing a voice (voices) or seeing something that was not there or not observed by others?

No, and has NOT experienced this in the past 2 weeks

No, but HAS experienced this in the past 2 weeks

Yes, HAS experienced this in the past 72 hours, but not currently

Yes, and IS CURRENTLY experiencing these thoughts or behaviors

In the past 72 hours: Has (person being assessed) used substances (alcohol, marijuana, illicit drugs) in a way that is unsafe, or show an inability to function without them?

No, and has NOT used in the past 2 weeks

No, but HAS used in the past 2 weeks

Yes, HAS used in the past 72 hours, but not currently

Yes, and IS CURRENTLY using/abusing substances

In the past 2 weeks: Has (person being assessed) shown severe mood swings, to have more energy than usual, noticeable excessive or fast speech, or less desire/need for sleep?

No, not at all

Yes, several days (in the past 2 weeks)

Yes, more than half the days (in the past 2 weeks)

Yes, almost every day (in the past 2 weeks)

Questionnaire is complete!