ADHD Online Assessment Questions Examples
Posted: Wed Oct 08, 2025 11:59 am
What current medical concerns are you dealing with or being treated for, including any mental health issues?
Have you had COVID-19?
Have you had persistent symptoms related to COVID, or long COVID symptoms?
Please provide a list of any surgical procedures you have experienced and the year of each procedure. If there was a reason the procedure was needed, please list that too. For example, a C-Section or a gallbladder surgery may not require additional reasoning, but if you had an exploratory procedure, or similar experience please provide additional details.
Please list all of your medications. Include the medication name as written on the bottle, the dose, the number of times per day and the diagnosis for which it was prescribed. Be sure to include any medications that help you with your thoughts and feelings.
Please list any over the counter medications, vitamins, or herbal supplements you use. Include any use of medical cannabis or compounded medications.
Have you ever been diagnosed with ADHD by a healthcare professional?
Please list any drug allergies you have, and describe the allergic reactions you experience.
Please share any experiences you feel important to include about your ADHD treatment history.
Have you ever been told by a healthcare professional that you do NOT have ADHD?
Please list any drug allergies you have, and describe the allergic reactions you experience.
Please share any additional information about your experience with medications that you believe would be helpful for us to know.
What is the highest grade level you completed in school?
Which type(s) of school(s) did you attend between kindergarten and 12th grade?
Have you ever had to repeat a grade in school?
As a student, do you have a 504 Accommodation Plan or Individualized Education Plan (IEP)? Or, as an employee, do you have any workplace accommodations?
Have you had any resource staff appointed by your school(s) to assist you?
Can you describe, in as much detail as you're comfortable with, any specific social or academic challenges you encountered or are currently facing in school?
Please share any feedback you received from teachers or other school staff.
Please share any other information that would be helpful to know about your schooling or education.
Have you ever worked with a therapist or counselor in the past?
Are you currently being prescribed medications by a psychiatrist or psychiatric nurse practitioner for mental health conditions?
Do you know of any complications your birth mother experienced during her pregnancy with you? If yes, please select all that apply:
Is there any other information about your birth history that you believe is important to include?
Do you know of any developmental concerns during your early childhood? If yes, please select the concerns from the options below:
Please add any additional details about your childhood development history that may be helpful to know.
To better understand your symptoms and health concerns, it's important to know if any of your biological relatives have a history of certain conditions. Do you have information about your biological parents, grandparents, siblings, or your children?
Have you faced any legal or law enforcement issues? Please know that you are safe and not judged by disclosing any legal history.
Please share any common lifestyle or family practices, viewpoints, or ways of life unique to your background that have shaped how you deal with information, manage stress, or express your emotions. This includes cultural influences.
In general, would you say your health is:
How frequently do you engage in exercise for 30 minutes or more?
What do you eat on a weekly basis? Check all that apply.
Please choose which meals you regularly consume.
How often do you consume energy drinks?
How often do consume other forms of caffeine on a daily basis such as soda, coffee, tea, or pills?
Have you ever felt like you're a "picky" eater or had strong dislikes for certain foods?
Is there anything else related to your diet, exercise, or health habits that you want us to know?
Do you smoke cigarettes?
Do you use nicotine products such as vapes, pouches, or gum?
Do you use CBD products without THC? For example, if you use topical CBD for pain or muscle soreness or take CBD gummies to help you sleep, calm down, or focus.
Can you select all the options that describe your overall home environment?
Please select the option that best describes your current living situation.
Please provide any additional details about your living situation. Share as much as you are comfortable with.
Please select all that apply to best describe who lives with or near you.
Is there any other information about your home environment that you believe would be helpful for us to know? This could involve details such as the presence of children, step-children, shared custody arrangements, pending adoptions, foster children, or the inclusion of elderly family members.
Please describe any recreational or social activities your family does together and how often.
How do spiritual or religious practices play a role in your household?
Do you regularly spend time in a place of worship, communal setting or other similar setting?
Are you currently involved in any sports?
Do you currently play any musical instruments?
Are you currently participating in the creative or performing arts?
How do you prefer to socialize?
On average, how frequently do you spend in-person time with friends?
If there is any additional information about your social life, that you believe would be helpful for us to know, please share it here.
Which of the following personality traits do you believe best describe you? Check all that apply.
How would others describe your personality traits? Check all that apply.
Do you have difficultly expressing your feelings?
Is there anything else related to personality traits that you would like to share?
In your own words, please describe your main concerns and the symptoms you are currently experiencing:
Can you help us understand why you decided to seek an evaluation at this time?
How far back do you recall experiencing these symptoms, even if you could not name them at the time?
How long have these symptoms been present?
When are these symptoms typically present?
How much do the symptoms you describe today impact your primary relationships, such as marriage/domestic partner, children, close family members or friends?
Describe how often your symptoms reported today affect your primary relationships. Please provide examples.
How much do the symptoms you describe today impact your financial well-being?
Describe how often your symptoms reported today affect your financial well-being. Please provide examples.
How much do the symptoms you describe today impact your experiences at social gatherings or events?
Describe how often your symptoms reported today affect your experiences at social gatherings or events. Please provide examples.
How much do the symptoms you describe today impact your life in communal settings, like places for shared activities, worship places, and similar settings?
Describe how often your symptoms reported today affect your life in communal or faith-based settings. Please provide examples.
How much do the symptoms you describe today impact your professional life or experiences at work?
Describe how often your symptoms reported today affect you while working. Please provide examples.
How much do the symptoms you describe today impact your participation in sports or the arts?
Describe how often your symptoms reported today affect your participation in sports or the arts. Please provide examples.
Which of the following emotional states best describes how you usually feel?
Are any of the following sensory items especially bothersome to you? Please check all that apply.
Are any of the following auditory items especially bothersome to you? Please check all that apply.
Are any of the following activities or experiences especially bothersome to you? Please check all that apply.
Please choose any symptoms that you may have experienced when you were young (before age 12). Select all that apply.
Have you experienced any stressful events or changes in the last 9 months? Please describe them. If there is more than one event, choose the one that has caused you the most distress.
How have you responded emotionally to this stressor?
Did the stressful event, that you experienced within the last 9 months, cause you to experience any of these depression symptoms?
Did the stressful event, that you experienced within the last 9 months, cause you to experience any of these anxiety symptoms?
Have you experienced stressful events longer than 9 months ago that continue to have a big impact on your mental well-being?
How often do you feel that you are "in tune" with the people around you?
How often do you feel that you lack companionship?
How often do you feel that there is no one you can turn to?
How often do you feel alone?
How often do you feel part of a group of friends?
How often do you feel that you have a lot in common with the people around you?
How often do you feel that you are no longer close to anyone?
How often do you feel that your interests and ideas are not shared by those around you?
How often do you feel close to people?
How often do you feel left out?
How often do you feel that your relationships with others are not meaningful?
How often do you feel that no one really knows you well?
How often do you feel isolated from others?
How often do you feel you can find companionship when you want it?
How often do you feel that there are people who really understand you?
How often do you feel shy?
How often do you feel that people are around you but not with you?
How often do you feel that there are people you can talk to?
How often do you feel that there are people you can turn to?
How often during the last year have you spent a lot of time thinking about social media or planned use of social media?
How often during the last year have you felt an urge to use social media more and more?
How often during the last year have you used social media in order to forget about personal problems?
How often during the last year have you tried to cut down on the use of social media without success?
How often during the last year have you become restless or troubled if you have been prohibited from using social media?
How often during the last year have you used social media so much that it has had a negative impact on your job/studies?
Instructions: Choose the option that best describes how you have felt and conducted yourself over the past one week.
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you find yourself talking too much when you are in social situations?
When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?
How often do you waste or mismanage time?
How often do you have trouble making a plan and sticking to it when you are in a situation where planful behavior is needed?
How often do you have difficulty prioritizing work when you are in a situation where setting priorities is needed?
How often do you depend on others to keep your life in order and attend to details?
How often do you put things off until the last minute?
How often do you have trouble remembering the main idea in things that you have read?
How often do you find that your mood is easily changeable?
How often do you feel more easily hassled or overwhelmed than other people in your situation?
How often do you have a hard time controlling your temper?
How often are your feelings easily hurt when you are criticized?
How often do you feel you lack self-discipline?
How often do you bore easily?
On average, how many hours of sleep do you usually get each night?
Consider the quality of your sleep recently. Do you wake up feeling rested most days?
How much do your sleep-wake issues impact your life at home, school, work, or in your relationships?
Have you ever encountered any of the following sleep issues? Check all that apply.
Are you currently experiencing any sleep issues (within the past 6 months)? Check all that apply.
The next 8 questions are about sleepiness. How likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times.
Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.
How likely are you to nod off or fall asleep while sitting and reading?
How likely are you to nod off or fall asleep while watching TV?
How likely are you to nod off or fall asleep while sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)?
How likely are you to nod off or fall asleep as a passenger in a car for an hour or more without stopping for a break?
How likely are you to nod off or fall asleep while lying down to rest when circumstances permit?
How likely are you to nod off or fall asleep while sitting and talking to someone?
How likely are you to nod off or fall asleep while sitting quietly after a meal without alcohol?
How likely are you to nod off or fall asleep while in a car, while stopped for a few minutes in traffic or at a light?
The Brief Dissociative Experiences Scale (DES-B)-Modified is an 8-item measure that assesses the severity of dissociative experiences in individuals age 18 and older. Each item asks the individual receiving care to rate the severity of their dissociative experiences during the past 7 days.
Instructions: Choose the option that best describes how you have felt over the past seven days.
I find myself staring into space and thinking of nothing.
People, objects, or the world around me seem strange or unreal.
I find that I did things that I do not remember doing.
When I am alone, I talk out loud to myself.
I feel as though I were looking at the world through a fog so that people and things seem far away or unclear.
I am able to ignore pain.
I act so differently from one situation to another that it is almost as if I were two different people.
I can do things very easily that would usually be hard for me.
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling or staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself.
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
In your lifetime, have you ever had persistent symptoms of depression? For example, feeling down, sad or hopeless, or having little interest or pleasure in doing things.
Are your depressive symptoms triggered by an event, or did they come on without a stressor?
Are your depressive symptoms triggered by substance use or recent substance use?
Have you ever received a depression-related diagnosis?
How far back, even into your childhood, do you recall experiencing depression symptoms, even if you could not name them at the time?
At present, how long have you been feeling symptoms of depression most days?
What is the longest you have experienced symptoms of depression continually?
Do you notice any symptoms of depression during your menstrual period, if applicable?
Have there been at least 6 different periods of time (at least 2 consecutive weeks) when you felt deeply depressed?
Did you have problems with depression before the age of 18?
Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?
Have you ever had a period of at least 1 week during which you needed much less sleep than usual?
Over the last two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Over the last two weeks, how often have you been bothered by not being able to stop or control worrying?
Over the last two weeks, how often have you been bothered by worrying too much about different things?
Over the last two weeks, how often have you been bothered by trouble relaxing?
Over the last two weeks, how often have you been bothered by being so restless that it is hard to sit still?
Over the last two weeks, how often have you been bothered by becoming easily annoyed or irritable?
Over the last two weeks, how often have you been bothered by feeling afraid, as if something awful might happen?
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Have there been symptoms of excessive anxiety or worry occurring more than 3-4 days per week for the last 6 months or longer?
What is the longest you have experienced symptoms of anxiety continuously?
Which of the following symptoms of anxiety have been present on a recurrent basis?
Please describe the details of your anxiety symptoms and how frequently they occur.
How much do you feel symptoms of anxiety are affecting daily function?
Are your anxiety symptoms triggered by an event, or did they come on without a stressor?
How far back, even into your childhood, do you recall having feelings of anxiety even if you could not name them at the time?
Have you ever received an anxiety-related diagnosis?
Have you experienced recurring episodes that you suspect to be panic attacks?
Are your panic attacks triggered by an event other than substance use, or did they come on without a stressor?
Are your panic attacks triggered by substance use or recent substance use?
Have you made any changes to your behavior as a result of experiencing panic attacks?
Have you ever had a panic attack that led to at least one month of continuous worry about having more panic attacks or major changes in your behavior?
Now, we'll discuss obsessive thoughts. These are intrusive and unwanted ideas, images, or impulses that repeatedly enter your mind. These thoughts can be distressing and hard to manage.
People dealing with obsessive thoughts often find them disruptive and may perform certain behaviors or mental routines to temporarily ease the anxiety linked to these thoughts. Obsessive thoughts are commonly associated with obsessive-compulsive disorder (OCD) but can also happen in other mental health conditions.
Are you experiencing obsessive thoughts?
How much of your time is occupied by obsessive thoughts?
On average, what is the longest number of consecutive waking hours per day that you are completely free of obsessive thoughts?
How much do your obsessive thoughts interfere with your social or work (or role) functioning? Is there anything that you don't do because of them?
How much distress do your obsessive thoughts cause you? In other words, how much anxiety is triggered by your obsessive thoughts?
How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind?
How much control do you have over your obsessive thoughts? How successful are you in diverting your excessive thinking? Can you dismiss them?
Compulsive behaviors are repetitive actions or rituals that individuals feel driven to do in response to distressing thoughts, called obsessive thoughts. These actions, like washing, checking, counting, or repeating tasks, offer temporary relief but don't address the underlying issues.
People with obsessive-compulsive disorder (OCD) may engage in these behaviors to reduce anxiety or prevent something they fear. Compulsive behaviors are commonly associated with OCD but can also happen in other mental health conditions.
Do you experience compulsive behaviors?
How much time do you spend performing compulsive behaviors? If you are having a hard time assessing the time spent on these, then think about how frequently they are performed.
On the average, what is the longest number of consecutive waking hours per day that you are completely free of compulsive behaviors? What is the longest block of time in which compulsions are absent?
How much do your compulsive behaviors interfere with your social or work (or role) functioning? Is there anything you don't do because of the compulsions?
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
How much of an effort do you make to resist the compulsions?
How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions?
The following questions ask about your eating patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to you.
Do you feel distressed about your episodes of excessive overeating?
During your episodes of excessive overeating, how often did you feel like you had no control over your eating (e.g., not being able to stop eating, feel compelled to eat, or going back and forth for more food)?
During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?
During your episodes of excessive overeating, how often were you embarrassed by how much you ate?
During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?
During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?
The following sets of questions are about your experience with alcohol and drug use or addiction. We understand that sometimes people over use, misuse or abuse substances to help them cope. We believe substance use and abuse can carry with it many challenges. Please know that you are safe and not judged by disclosing your use of alcohol and/or drugs.
Units are a simple way of expressing the quantity of pure alcohol in a drink. One unit of alcohol is about 10ml or 8gm of pure alcohol. That is the amount of alcohol that most adults can process in about an hour.
Risks associated with alcohol use become higher if the number of units of alcohol consumed are greater than 14 per week.
One way to improve your health is to reduce the number of units of alcohol you drink each week. Any reduction is a good thing, and a safe goal is less than 14 units per week.
Here is a sample list of common beverages containing alcohol:
A single shot (25-30 mls) of Spirits like gin, rum, whiskey, vodka, tequila = 1 unit
A small glass of wine (120 mls or about 1/2 cup) = 1.5 units
Bottle of lager, beer or cider (12 oz) = 1.7 units
Large can of lager, beer or cider (16 oz) = 2.4 units
Here is a sample list of common beverages containing alcohol:
A single shot (25-30 mls) of Spirits like gin, rum, whiskey, vodka, tequila = 1 unit
A small glass of wine (120 mls or about 1/2 cup) = 1.5 units
Bottle of lager, beer or cider (12 oz) = 1.7 units
Large can of lager, beer or cider (16 oz) = 2.4 units
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
Here is a sample list of common beverages containing alcohol:
A single shot (25-30 mls) of Spirits like gin, rum, whiskey, vodka, tequila = 1 unit
A small glass of wine (120 mls or about 1/2 cup) = 1.5 units
Bottle of lager, beer or cider (12 oz) = 1.7 units
Large can of lager, beer or cider (16 oz) = 2.4 units
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
Have you or somebody else been injured as a result of your drinking?
Is there anything else that you think would be important to share with us about your experience with alcohol use?
Have you ever been in treatment for substance abuse?
Have you ever used any of these drugs? Check all that apply:
These next questions address difficult experiences you may have had with abuse or trauma. It's okay to take a break if you start feeling uncomfortable or triggered. When you're ready to continue, you can pick up where you left off.
Do you have any history of being physically abused?
Are you currently experiencing any physical abuse?
Do you have any history of being mentally abused?
Are you currently experiencing any mental abuse?
Do you have any history of being sexually abused?
Are you currently experiencing any sexual abuse?
Please indicate if you have experienced any of these traumatic life events. Check all that apply.
Were there any other traumatic or stressful events you would like us to know about?
Please explain how your past trauma is connected to your current symptoms. For instance, did the symptoms you're facing now begin before or after you went through those traumatic events?
People sometimes have problems after extremely stressful events or experiences. The following questions pertain to the past 7 days. How much have you been bothered during the PAST SEVEN (7) DAYS by each of the following problems that occurred or became worse after an extremely stressful event or experience?
How much have you been bothered during the past 7 days by having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?
How much have you been bothered during the past 7 days by having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?
How much have you been bothered during the past 7 days by feeling very emotionally upset when something reminded you of a stressful experience?
How much have you been bothered during the past 7 days by trying to avoid thoughts, feelings, or physical sensations that reminded you of a stressful experience?
How much have you been bothered during the past 7 days by thinking that a stressful event happened because you or someone else (who didn’t directly harm you) did something wrong or didn’t do everything possible to prevent it, or because of something about you?
How much have you been bothered during the past 7 days by having a very negative emotional state (for example, you were experiencing lots of fear, anger, guilt, shame, or horror) after a stressful experience?
How much have you been bothered during the past 7 days by losing interest in activities you used to enjoy before having a stressful experience?
How much have you been bothered during the past 7 days by being “super alert,” on guard, or constantly on the lookout for danger?
How much have you been bothered during the past 7 days by feeling jumpy or easily startled when you hear an unexpected noise?
How much have you been bothered during the past 7 days by being extremely irritable or angry to the point where you yelled at other people, got into fights, or destroyed things?
You are almost done, just a few more questions to go. The following questions address self-harm and suicidal thoughts. Please remember you can take a break and come back if you feel triggered or at all uncomfortable. Simply step away, and when you return you can pick up right where you left off. Select Proceed to begin the final set of questions.
Have you ever done any of the following with the purpose of intentionally hurting yourself?
Are there any other ways that you have physically hurt or mutilated your body with the purpose of intentionally hurting yourself?
In the past month, have you wished you were dead or wished you would go to sleep and not wake up?
In the past month, have you actually had any thoughts of killing yourself?
Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
If you're experiencing thoughts of suicide with a plan, it's crucial to act now.
Please go directly to the nearest emergency room or text or call the Suicide & Crisis Lifeline at 988 from your mobile device.
You can also access immediate support via Live Chat at 988lifeline.org. Your well-being matters, and help is available 24/7. Don't wait. Reach out for support now.
Have you had COVID-19?
Have you had persistent symptoms related to COVID, or long COVID symptoms?
Please provide a list of any surgical procedures you have experienced and the year of each procedure. If there was a reason the procedure was needed, please list that too. For example, a C-Section or a gallbladder surgery may not require additional reasoning, but if you had an exploratory procedure, or similar experience please provide additional details.
Please list all of your medications. Include the medication name as written on the bottle, the dose, the number of times per day and the diagnosis for which it was prescribed. Be sure to include any medications that help you with your thoughts and feelings.
Please list any over the counter medications, vitamins, or herbal supplements you use. Include any use of medical cannabis or compounded medications.
Have you ever been diagnosed with ADHD by a healthcare professional?
Please list any drug allergies you have, and describe the allergic reactions you experience.
Please share any experiences you feel important to include about your ADHD treatment history.
Have you ever been told by a healthcare professional that you do NOT have ADHD?
Please list any drug allergies you have, and describe the allergic reactions you experience.
Please share any additional information about your experience with medications that you believe would be helpful for us to know.
What is the highest grade level you completed in school?
Which type(s) of school(s) did you attend between kindergarten and 12th grade?
Have you ever had to repeat a grade in school?
As a student, do you have a 504 Accommodation Plan or Individualized Education Plan (IEP)? Or, as an employee, do you have any workplace accommodations?
Have you had any resource staff appointed by your school(s) to assist you?
Can you describe, in as much detail as you're comfortable with, any specific social or academic challenges you encountered or are currently facing in school?
Please share any feedback you received from teachers or other school staff.
Please share any other information that would be helpful to know about your schooling or education.
Have you ever worked with a therapist or counselor in the past?
Are you currently being prescribed medications by a psychiatrist or psychiatric nurse practitioner for mental health conditions?
Do you know of any complications your birth mother experienced during her pregnancy with you? If yes, please select all that apply:
Is there any other information about your birth history that you believe is important to include?
Do you know of any developmental concerns during your early childhood? If yes, please select the concerns from the options below:
Please add any additional details about your childhood development history that may be helpful to know.
To better understand your symptoms and health concerns, it's important to know if any of your biological relatives have a history of certain conditions. Do you have information about your biological parents, grandparents, siblings, or your children?
Have you faced any legal or law enforcement issues? Please know that you are safe and not judged by disclosing any legal history.
Please share any common lifestyle or family practices, viewpoints, or ways of life unique to your background that have shaped how you deal with information, manage stress, or express your emotions. This includes cultural influences.
In general, would you say your health is:
How frequently do you engage in exercise for 30 minutes or more?
What do you eat on a weekly basis? Check all that apply.
Please choose which meals you regularly consume.
How often do you consume energy drinks?
How often do consume other forms of caffeine on a daily basis such as soda, coffee, tea, or pills?
Have you ever felt like you're a "picky" eater or had strong dislikes for certain foods?
Is there anything else related to your diet, exercise, or health habits that you want us to know?
Do you smoke cigarettes?
Do you use nicotine products such as vapes, pouches, or gum?
Do you use CBD products without THC? For example, if you use topical CBD for pain or muscle soreness or take CBD gummies to help you sleep, calm down, or focus.
Can you select all the options that describe your overall home environment?
Please select the option that best describes your current living situation.
Please provide any additional details about your living situation. Share as much as you are comfortable with.
Please select all that apply to best describe who lives with or near you.
Is there any other information about your home environment that you believe would be helpful for us to know? This could involve details such as the presence of children, step-children, shared custody arrangements, pending adoptions, foster children, or the inclusion of elderly family members.
Please describe any recreational or social activities your family does together and how often.
How do spiritual or religious practices play a role in your household?
Do you regularly spend time in a place of worship, communal setting or other similar setting?
Are you currently involved in any sports?
Do you currently play any musical instruments?
Are you currently participating in the creative or performing arts?
How do you prefer to socialize?
On average, how frequently do you spend in-person time with friends?
If there is any additional information about your social life, that you believe would be helpful for us to know, please share it here.
Which of the following personality traits do you believe best describe you? Check all that apply.
How would others describe your personality traits? Check all that apply.
Do you have difficultly expressing your feelings?
Is there anything else related to personality traits that you would like to share?
In your own words, please describe your main concerns and the symptoms you are currently experiencing:
Can you help us understand why you decided to seek an evaluation at this time?
How far back do you recall experiencing these symptoms, even if you could not name them at the time?
How long have these symptoms been present?
When are these symptoms typically present?
How much do the symptoms you describe today impact your primary relationships, such as marriage/domestic partner, children, close family members or friends?
Describe how often your symptoms reported today affect your primary relationships. Please provide examples.
How much do the symptoms you describe today impact your financial well-being?
Describe how often your symptoms reported today affect your financial well-being. Please provide examples.
How much do the symptoms you describe today impact your experiences at social gatherings or events?
Describe how often your symptoms reported today affect your experiences at social gatherings or events. Please provide examples.
How much do the symptoms you describe today impact your life in communal settings, like places for shared activities, worship places, and similar settings?
Describe how often your symptoms reported today affect your life in communal or faith-based settings. Please provide examples.
How much do the symptoms you describe today impact your professional life or experiences at work?
Describe how often your symptoms reported today affect you while working. Please provide examples.
How much do the symptoms you describe today impact your participation in sports or the arts?
Describe how often your symptoms reported today affect your participation in sports or the arts. Please provide examples.
Which of the following emotional states best describes how you usually feel?
Are any of the following sensory items especially bothersome to you? Please check all that apply.
Are any of the following auditory items especially bothersome to you? Please check all that apply.
Are any of the following activities or experiences especially bothersome to you? Please check all that apply.
Please choose any symptoms that you may have experienced when you were young (before age 12). Select all that apply.
Have you experienced any stressful events or changes in the last 9 months? Please describe them. If there is more than one event, choose the one that has caused you the most distress.
How have you responded emotionally to this stressor?
Did the stressful event, that you experienced within the last 9 months, cause you to experience any of these depression symptoms?
Did the stressful event, that you experienced within the last 9 months, cause you to experience any of these anxiety symptoms?
Have you experienced stressful events longer than 9 months ago that continue to have a big impact on your mental well-being?
How often do you feel that you are "in tune" with the people around you?
How often do you feel that you lack companionship?
How often do you feel that there is no one you can turn to?
How often do you feel alone?
How often do you feel part of a group of friends?
How often do you feel that you have a lot in common with the people around you?
How often do you feel that you are no longer close to anyone?
How often do you feel that your interests and ideas are not shared by those around you?
How often do you feel close to people?
How often do you feel left out?
How often do you feel that your relationships with others are not meaningful?
How often do you feel that no one really knows you well?
How often do you feel isolated from others?
How often do you feel you can find companionship when you want it?
How often do you feel that there are people who really understand you?
How often do you feel shy?
How often do you feel that people are around you but not with you?
How often do you feel that there are people you can talk to?
How often do you feel that there are people you can turn to?
How often during the last year have you spent a lot of time thinking about social media or planned use of social media?
How often during the last year have you felt an urge to use social media more and more?
How often during the last year have you used social media in order to forget about personal problems?
How often during the last year have you tried to cut down on the use of social media without success?
How often during the last year have you become restless or troubled if you have been prohibited from using social media?
How often during the last year have you used social media so much that it has had a negative impact on your job/studies?
Instructions: Choose the option that best describes how you have felt and conducted yourself over the past one week.
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you find yourself talking too much when you are in social situations?
When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?
How often do you waste or mismanage time?
How often do you have trouble making a plan and sticking to it when you are in a situation where planful behavior is needed?
How often do you have difficulty prioritizing work when you are in a situation where setting priorities is needed?
How often do you depend on others to keep your life in order and attend to details?
How often do you put things off until the last minute?
How often do you have trouble remembering the main idea in things that you have read?
How often do you find that your mood is easily changeable?
How often do you feel more easily hassled or overwhelmed than other people in your situation?
How often do you have a hard time controlling your temper?
How often are your feelings easily hurt when you are criticized?
How often do you feel you lack self-discipline?
How often do you bore easily?
On average, how many hours of sleep do you usually get each night?
Consider the quality of your sleep recently. Do you wake up feeling rested most days?
How much do your sleep-wake issues impact your life at home, school, work, or in your relationships?
Have you ever encountered any of the following sleep issues? Check all that apply.
Are you currently experiencing any sleep issues (within the past 6 months)? Check all that apply.
The next 8 questions are about sleepiness. How likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times.
Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.
How likely are you to nod off or fall asleep while sitting and reading?
How likely are you to nod off or fall asleep while watching TV?
How likely are you to nod off or fall asleep while sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)?
How likely are you to nod off or fall asleep as a passenger in a car for an hour or more without stopping for a break?
How likely are you to nod off or fall asleep while lying down to rest when circumstances permit?
How likely are you to nod off or fall asleep while sitting and talking to someone?
How likely are you to nod off or fall asleep while sitting quietly after a meal without alcohol?
How likely are you to nod off or fall asleep while in a car, while stopped for a few minutes in traffic or at a light?
The Brief Dissociative Experiences Scale (DES-B)-Modified is an 8-item measure that assesses the severity of dissociative experiences in individuals age 18 and older. Each item asks the individual receiving care to rate the severity of their dissociative experiences during the past 7 days.
Instructions: Choose the option that best describes how you have felt over the past seven days.
I find myself staring into space and thinking of nothing.
People, objects, or the world around me seem strange or unreal.
I find that I did things that I do not remember doing.
When I am alone, I talk out loud to myself.
I feel as though I were looking at the world through a fog so that people and things seem far away or unclear.
I am able to ignore pain.
I act so differently from one situation to another that it is almost as if I were two different people.
I can do things very easily that would usually be hard for me.
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling or staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself.
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
In your lifetime, have you ever had persistent symptoms of depression? For example, feeling down, sad or hopeless, or having little interest or pleasure in doing things.
Are your depressive symptoms triggered by an event, or did they come on without a stressor?
Are your depressive symptoms triggered by substance use or recent substance use?
Have you ever received a depression-related diagnosis?
How far back, even into your childhood, do you recall experiencing depression symptoms, even if you could not name them at the time?
At present, how long have you been feeling symptoms of depression most days?
What is the longest you have experienced symptoms of depression continually?
Do you notice any symptoms of depression during your menstrual period, if applicable?
Have there been at least 6 different periods of time (at least 2 consecutive weeks) when you felt deeply depressed?
Did you have problems with depression before the age of 18?
Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?
Have you ever had a period of at least 1 week during which you needed much less sleep than usual?
Over the last two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Over the last two weeks, how often have you been bothered by not being able to stop or control worrying?
Over the last two weeks, how often have you been bothered by worrying too much about different things?
Over the last two weeks, how often have you been bothered by trouble relaxing?
Over the last two weeks, how often have you been bothered by being so restless that it is hard to sit still?
Over the last two weeks, how often have you been bothered by becoming easily annoyed or irritable?
Over the last two weeks, how often have you been bothered by feeling afraid, as if something awful might happen?
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Have there been symptoms of excessive anxiety or worry occurring more than 3-4 days per week for the last 6 months or longer?
What is the longest you have experienced symptoms of anxiety continuously?
Which of the following symptoms of anxiety have been present on a recurrent basis?
Please describe the details of your anxiety symptoms and how frequently they occur.
How much do you feel symptoms of anxiety are affecting daily function?
Are your anxiety symptoms triggered by an event, or did they come on without a stressor?
How far back, even into your childhood, do you recall having feelings of anxiety even if you could not name them at the time?
Have you ever received an anxiety-related diagnosis?
Have you experienced recurring episodes that you suspect to be panic attacks?
Are your panic attacks triggered by an event other than substance use, or did they come on without a stressor?
Are your panic attacks triggered by substance use or recent substance use?
Have you made any changes to your behavior as a result of experiencing panic attacks?
Have you ever had a panic attack that led to at least one month of continuous worry about having more panic attacks or major changes in your behavior?
Now, we'll discuss obsessive thoughts. These are intrusive and unwanted ideas, images, or impulses that repeatedly enter your mind. These thoughts can be distressing and hard to manage.
People dealing with obsessive thoughts often find them disruptive and may perform certain behaviors or mental routines to temporarily ease the anxiety linked to these thoughts. Obsessive thoughts are commonly associated with obsessive-compulsive disorder (OCD) but can also happen in other mental health conditions.
Are you experiencing obsessive thoughts?
How much of your time is occupied by obsessive thoughts?
On average, what is the longest number of consecutive waking hours per day that you are completely free of obsessive thoughts?
How much do your obsessive thoughts interfere with your social or work (or role) functioning? Is there anything that you don't do because of them?
How much distress do your obsessive thoughts cause you? In other words, how much anxiety is triggered by your obsessive thoughts?
How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind?
How much control do you have over your obsessive thoughts? How successful are you in diverting your excessive thinking? Can you dismiss them?
Compulsive behaviors are repetitive actions or rituals that individuals feel driven to do in response to distressing thoughts, called obsessive thoughts. These actions, like washing, checking, counting, or repeating tasks, offer temporary relief but don't address the underlying issues.
People with obsessive-compulsive disorder (OCD) may engage in these behaviors to reduce anxiety or prevent something they fear. Compulsive behaviors are commonly associated with OCD but can also happen in other mental health conditions.
Do you experience compulsive behaviors?
How much time do you spend performing compulsive behaviors? If you are having a hard time assessing the time spent on these, then think about how frequently they are performed.
On the average, what is the longest number of consecutive waking hours per day that you are completely free of compulsive behaviors? What is the longest block of time in which compulsions are absent?
How much do your compulsive behaviors interfere with your social or work (or role) functioning? Is there anything you don't do because of the compulsions?
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
How much of an effort do you make to resist the compulsions?
How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions?
The following questions ask about your eating patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to you.
Do you feel distressed about your episodes of excessive overeating?
During your episodes of excessive overeating, how often did you feel like you had no control over your eating (e.g., not being able to stop eating, feel compelled to eat, or going back and forth for more food)?
During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?
During your episodes of excessive overeating, how often were you embarrassed by how much you ate?
During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?
During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?
The following sets of questions are about your experience with alcohol and drug use or addiction. We understand that sometimes people over use, misuse or abuse substances to help them cope. We believe substance use and abuse can carry with it many challenges. Please know that you are safe and not judged by disclosing your use of alcohol and/or drugs.
Units are a simple way of expressing the quantity of pure alcohol in a drink. One unit of alcohol is about 10ml or 8gm of pure alcohol. That is the amount of alcohol that most adults can process in about an hour.
Risks associated with alcohol use become higher if the number of units of alcohol consumed are greater than 14 per week.
One way to improve your health is to reduce the number of units of alcohol you drink each week. Any reduction is a good thing, and a safe goal is less than 14 units per week.
Here is a sample list of common beverages containing alcohol:
A single shot (25-30 mls) of Spirits like gin, rum, whiskey, vodka, tequila = 1 unit
A small glass of wine (120 mls or about 1/2 cup) = 1.5 units
Bottle of lager, beer or cider (12 oz) = 1.7 units
Large can of lager, beer or cider (16 oz) = 2.4 units
Here is a sample list of common beverages containing alcohol:
A single shot (25-30 mls) of Spirits like gin, rum, whiskey, vodka, tequila = 1 unit
A small glass of wine (120 mls or about 1/2 cup) = 1.5 units
Bottle of lager, beer or cider (12 oz) = 1.7 units
Large can of lager, beer or cider (16 oz) = 2.4 units
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
Here is a sample list of common beverages containing alcohol:
A single shot (25-30 mls) of Spirits like gin, rum, whiskey, vodka, tequila = 1 unit
A small glass of wine (120 mls or about 1/2 cup) = 1.5 units
Bottle of lager, beer or cider (12 oz) = 1.7 units
Large can of lager, beer or cider (16 oz) = 2.4 units
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
Have you or somebody else been injured as a result of your drinking?
Is there anything else that you think would be important to share with us about your experience with alcohol use?
Have you ever been in treatment for substance abuse?
Have you ever used any of these drugs? Check all that apply:
These next questions address difficult experiences you may have had with abuse or trauma. It's okay to take a break if you start feeling uncomfortable or triggered. When you're ready to continue, you can pick up where you left off.
Do you have any history of being physically abused?
Are you currently experiencing any physical abuse?
Do you have any history of being mentally abused?
Are you currently experiencing any mental abuse?
Do you have any history of being sexually abused?
Are you currently experiencing any sexual abuse?
Please indicate if you have experienced any of these traumatic life events. Check all that apply.
Were there any other traumatic or stressful events you would like us to know about?
Please explain how your past trauma is connected to your current symptoms. For instance, did the symptoms you're facing now begin before or after you went through those traumatic events?
People sometimes have problems after extremely stressful events or experiences. The following questions pertain to the past 7 days. How much have you been bothered during the PAST SEVEN (7) DAYS by each of the following problems that occurred or became worse after an extremely stressful event or experience?
How much have you been bothered during the past 7 days by having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?
How much have you been bothered during the past 7 days by having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?
How much have you been bothered during the past 7 days by feeling very emotionally upset when something reminded you of a stressful experience?
How much have you been bothered during the past 7 days by trying to avoid thoughts, feelings, or physical sensations that reminded you of a stressful experience?
How much have you been bothered during the past 7 days by thinking that a stressful event happened because you or someone else (who didn’t directly harm you) did something wrong or didn’t do everything possible to prevent it, or because of something about you?
How much have you been bothered during the past 7 days by having a very negative emotional state (for example, you were experiencing lots of fear, anger, guilt, shame, or horror) after a stressful experience?
How much have you been bothered during the past 7 days by losing interest in activities you used to enjoy before having a stressful experience?
How much have you been bothered during the past 7 days by being “super alert,” on guard, or constantly on the lookout for danger?
How much have you been bothered during the past 7 days by feeling jumpy or easily startled when you hear an unexpected noise?
How much have you been bothered during the past 7 days by being extremely irritable or angry to the point where you yelled at other people, got into fights, or destroyed things?
You are almost done, just a few more questions to go. The following questions address self-harm and suicidal thoughts. Please remember you can take a break and come back if you feel triggered or at all uncomfortable. Simply step away, and when you return you can pick up right where you left off. Select Proceed to begin the final set of questions.
Have you ever done any of the following with the purpose of intentionally hurting yourself?
Are there any other ways that you have physically hurt or mutilated your body with the purpose of intentionally hurting yourself?
In the past month, have you wished you were dead or wished you would go to sleep and not wake up?
In the past month, have you actually had any thoughts of killing yourself?
Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
If you're experiencing thoughts of suicide with a plan, it's crucial to act now.
Please go directly to the nearest emergency room or text or call the Suicide & Crisis Lifeline at 988 from your mobile device.
You can also access immediate support via Live Chat at 988lifeline.org. Your well-being matters, and help is available 24/7. Don't wait. Reach out for support now.