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Home » ALASKA SCREENING TOOL

Alaska Screening Tool

Alaska Screening Tool
Client Name*
First Last
Client Number:
Staff Name
First Last
Date*
Month
Day
Year
Instructions: Please answer these ques ons to make sure your needs are identified. Your answers are important to help us serve you better. If you are filling this out for someone else, please answer from their view. Parents or guardians usually complete the survey on behalf of children under age 13.
Section 1 - Please estimate the number of days in the last 2 weeks
Enter a number from 1-14 days:
1. Over the last two weeks, how many days have you felt little interest or pleasure in doing things?*
Please enter a number from 0 to 14.
2. How many days have you felt down, depressed or hopeless?*
Please enter a number from 0 to 14.
3. Had trouble falling asleep or staying asleep or sleeping too much?*
Please enter a number from 0 to 14.
4. Felt tired or had little energy?*
Please enter a number from 0 to 14.
5. Had a poor appetite or ate too much?*
Please enter a number from 0 to 14.
6. Felt bad about yourself or that you were a failure or had let yourself or your family down?*
Please enter a number from 0 to 14.
7. Had trouble concentraing on things, such as reading the newspaper or watching TV?*
Please enter a number from 0 to 14.
8. Moved or spoken so slowly that other people could have noticed?*
Please enter a number from 0 to 14.
9. Been so fidgety or restless that you were moving around a lot more than usual?*
Please enter a number from 0 to 14.
10. Remembered things that were extremely unpleasant?*
Please enter a number from 0 to 14.
11. Were barely able to control your anger?*
Please enter a number from 0 to 14.
12. Felt numb, detached, or disconnected?*
Please enter a number from 0 to 14.
13. Felt distant or cut off from other people?*
Please enter a number from 0 to 14.
Section 2 - Please check the answer to the following questons based on your lifetime.
14. I have lived where I often or very often felt like I didn’t have enough to eat, had to wear dirty clothes, or was not safe*
- Yes
- No
15. I have lived with someone who was a problem drinker or alcoholic, or who used street drugs*
- Yes
- No
16. I have lived with someone who was seriously depressed or seriously mentally ill*
- Yes
- No
17. I have lived with someone who attempted suicide or completed suicide*
- Yes
- No
18. I have lived with someone who was sent to prison*
- Yes
- No
19. I, or a close family member, was placed in foster care*
- Yes
- No
20. I have lived with someone while they were physically mistreated or seriously threatened*
- Yes
- No
21a. I have been physically mistreated or seriously threatened*
- Yes
- No
21b. If you answered “Yes”, did this involve your in mate partner (spouse, girlfriend, or boyfriend)?*
- Yes
- No
Section 3 - Please answer the following questions based on your lifetime
(D/N = Don’t Know)
22. I have had a blow to the head that was severe enough to make me lose consciousness*
- Yes
- No
- D/N
23. I have had a blow to the head that was severe enough to cause a concussion*
- Yes
- No
- D/N
23a - If you answered “Yes” to 23 - Did you receive treatment for the head injury?*
- Yes
- No
23b - If you answered “Yes” to 23 - After the head injury, was there a permanent change in anything?*
- Yes
- No
23b - If you answered “Yes” to 23 - After the head injury, was there a permanent change in anything?*
- Yes
- No
23b - If you answered “Yes” to 23 - Did you receive treatment for anything that changed?*
- Yes
- No
24. Did your mother ever consume alcohol?*
- Yes
- No
- D/N
24a - If Yes, did she con nue to drink during her pregnancy with you?*
- Yes
- No
- D/N
Section 5 – Please answer the following questions based on the past 12 months.
(D/N = Don’t Know)
25. Have you had a major life change like death of a loved one, moving, or loss of a job?*
- Yes
- No
26. Do you sometimes feel afraid, panicky, nervous or scared?*
- Yes
- No
27. Do you often find yourself in situatons where your heart pounds and you feel anxious and want to get away?*
- Yes
- No
28. Have you tried to hurt yourself or commit suicide?*
- Yes
- No
29. Have you destroyed property or set a fire that caused damage?*
- Yes
- No
30. Have you physically harmed or threatened to harm an animal or person on purpose?*
- Yes
- No
31. Do you ever hear voices or see things that other people tell you they don’t see or hear?*
- Yes
- No
32. Do you think people are out to get you and you have to watch your step?*
- Yes
- No
Section 5 – Please answer the following questions based on the past 12 months.
(D/N = Don’t Know)
33. Have you gotten into trouble at home, at school, or in the community, because of using alcohol, drugs, or inhalants?*
- Yes
- No
34. Have you missed school or work because of using alcohol, drugs, or inhalants?*
- Yes
- No
35. In the past year have you ever had 6 or more drinks at any one time?*
- Yes
- No
36. Does it make you angry if someone tells you that you drink or use drugs, or inhalants too much?*
- Yes
- No
37. Do you think you might have a problem with alcohol, drug or inhalant use?*
- Yes
- No
THANK YOU for providing this informa on! Your answers are important to help us serve you better.

Wasilla

907-313-1333

907-357-8781

591 S. Knik Goose Bay Rd

Wasilla, Alaska 99654

Fairbanks

907-313-1333

4880 Old Airport Way

Fairbanks, Alaska 99709

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