Child/Adolescent Intake Packet

LEVEL 2—Anger—Parent/Guardian of Child Age 6-17*

* PROMIS Emotional Distress—Calibrated Anger Measure—Parent (This measure was not tested in the DSM-5 Field Trials) Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by “seeming irritated or easily annoyed” and/or “seeming angry or lost his/her temper” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking one box per row.

In the past SEVEN (7) days has my child felt mad?*

In the past SEVEN (7) days was my child so angry he/she felt like throwing something?*

In the past SEVEN (7) days has my child felt upset?*

In the past SEVEN (7) days when my child got mad, did he/she stay mad?*

LEVEL 2—Irritability—Parent/Guardian of Child Age 6-17*

* Affective Reactivity Index (ARI) Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by “seeming irritated or easily annoyed” and/or “seeming angry or lost his/her temper” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking one box per row.

In the past SEVEN (7) days and compared to others of the same age, is my child easily annoyed by others?*

Not true
Somewhat true
Certainly true

In the past SEVEN (7) days and compared to others of the same age, does my child often lose his/her temper?*

Not true
Somewhat true
Certainly true

In the past SEVEN (7) days and compared to others of the same age, does my child stay angry for a long time?*

Not true
Somewhat true
Certainly true

In the past SEVEN (7) days and compared to others of the same age, is my child angry most of the time?*

Not true
Somewhat true
Certainly true

In the past SEVEN (7) days and compared to others of the same age, does my child get angry frequently?*

Not true
Somewhat true
Certainly true

In the past SEVEN (7) days and compared to others of the same age, does my child lose their temper easily?*

Not true
Somewhat true
Certainly true

In the past SEVEN (7) days and compared to others of the same age, does my child's overall irritability cause him/her problems?*

Not true
Somewhat true
Certainly true

LEVEL 2—Mania—Parent/Guardian of Child Age 6-17*

* Adapted from the Altman Self-Rating Mania Scale (ASRM) Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by “sleeping less than usual, but still have a lot of energy” and/or “only sleeping for a short time at night” at a mild or greater level of severity. The five statement groups or questions below ask about these feelings in more detail. Please read each group of statements/question carefully. Choose the one statement in each group that best describes the way your child has been feeling for the past week. Check the box next to the number/statement selected. Please note: The word “occasionally” when used here means once or twice; “often” means several times or more and “frequently” means most of the time.

Question 1*

(1) He/she does not feel happier or more cheerful than usual.
(2) He/she occasionally feels happier or more cheerful than usual.
(3) He/she often feels happier or more cheerful than usual.
(4) He/she feels happier or more cheerful than usual most of the time.
(5) He/she feels happier or more cheerful than usual all of the time.

Question 2*

(1) He/she does not feel more self-confident than usual.
(2) He/she occasionally feels more self-confident than usual.
(3) He/she often feels more self-confident than usual.
(4) He/she frequently feels more self-confident than usual.
(5) He/she feels extremely self-confident all of the time.

Question 3*

(1) He/she does not need less sleep than usual.
(2) He/she occasionally needs less sleep than usual.
(3) He/she often needs less sleep than usual.
(4) He/she frequently needs less sleep than usual.
(5) He/she can go all day and all night without any sleep and still not feel tired.

Question 4*

(1) He/she does not talk more than usual.
(2) He/she occasionally talks more than usual.
(3) He/she often talks more than usual.
(4) He/she frequently talks more than usual.
(5) He/she talks constantly and cannot be interrupted.

Question 5*

(1) He/she has not been more active (either socially, sexually, at work, home, or school) than usual.
(2) He/she has occasionally been more active than usual.
(3) He/she has often been more active than usual.
(4) He/she has frequently been more active than usual.
(5) He/she is constantly more active or on the go all the time.

LEVEL 2—Anxiety—Parent/Guardian of Child Age 6-17*

* Adapted from PROMIS Emotional Distress—Anxiety—Parent Item Bank Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by “feeling nervous, anxious, or scared”, “not being able to stop worrying”, and/or “couldn’t do things he/she wanted to or should have done because they made him/her feel nervous” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking one box per row.

In the past SEVEN (7) DAYS, has my child said that he/she felt like something awful might happen?*

In the past SEVEN (7) DAYS, has my child said that he/she felt nervous?*

In the past SEVEN (7) DAYS, has my child said that he/she felt scared?*

In the past SEVEN (7) DAYS, has my child said that he/she felt worried?*

In the past SEVEN (7) DAYS, has my child said that he/she felt worried about what could happen to him/her?*

In the past SEVEN (7) DAYS, has my child said that he/she felt worried when he/she went to bed at night?*

In the past SEVEN (7) DAYS, has my child said that he/she got scared really easily?*

In the past SEVEN (7) DAYS, has my child said that he/she afraid of going to school?*

In the past SEVEN (7) DAYS, has my child said that he/she worried when he/she was at home?*

In the past SEVEN (7) DAYS, has my child said that he/she worried when he/she was away from home?*

LEVEL 2—Substance Use—Parent/Guardian of Child Age 6-17*

* Adapted from the NIDA-Modified ASSIST Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by “having an alcoholic beverage”; “smoking a cigarette, a cigar, or pipe or used snuff or chewing tobacco”; “using drugs like marijuana, cocaine or crack, club drugs, hallucinogens, heroin, inhalants or solvents, or methamphetamine”; and/or “using any medicine without a doctor’s prescription.” The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past two (2) weeks. Please respond to each item by marking one box per row.

During the past TWO (2) WEEKS, about how often did your child have an alcoholic beverage (beer, wine, liquor, etc.)?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child have 4 or more drinks in a single day?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child smoke a cigarette, a cigar, or pipe or used snuff or chewing tobacco?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use painkillers (like Vicodin)?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use stimulants (like Ritalin, Adderall)*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use sedatives or tranquilizers (like sleeping pills or Valium)*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use steroids?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use other medicines?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

If they have used other medicines, what kind?*

During the past TWO (2) WEEKS, about how often did your child use marijuana?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use cocaine or crack?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use club drugs (like ecstasy)?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use hallucinogens (like LSD)?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use heroin?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use inhalants or solvents (like glue)?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

During the past TWO (2) WEEKS, about how often did your child use methamphetamines (like speed)?*

Not at all
Less than a day or two
Several days
More than half the days
Nearly every day
Don't know

Medication	Dose	Directions	Date/Time of Last Dose

Medication	Dose	Length of Use	Reason for Discontinuing

Relationship	Name	Age	Sex	Occupation	Education (Highest Level)	Religion	Living in home?

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