Today M-D-Y
Are you taking this for yourself, or on behalf of someone else?
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Self
Someone else
Where did you hear about us?
Outreach event EIP Line Psychology Today University Counseling Center Google/Online Search Online Training Clinician/Treatment Provider Other
younger than 8 years old 8-11 years old 12-13 years old 14-15 years old 16-17 years old 18-19 years old 20-21 years old 22-23 years old 24-25 years old 26+ years old
Please indicate which race you identify with (select all that apply):
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Please specify your gender identity:
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Female
Male
Non-binary / third gender
Trans male
Trans female
Prefer to self-describe
Prefer not to say
Please specify your relationship to the person are taking this for:
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Parent Friend Provider/Clinician Teacher Other Prefer not to say
Please specify your relationship with the person for whom you are taking this survey
Please provide your name:
Please provide the name of the person you are taking this for:
Please provide the age of the person you are taking this for:
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younger than 8 years old 8-11 years old 12-13 years old 14-15 years old 16-17 years old 18-19 years old 20-21 years old 22-23 years old 24-25 years old 26+ years old Prefer not to say
Please indicate the racial identity of the person for whom you are filling this out (select all that apply):
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Please specify the gender identity of the person for whom you are filling this out:
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Female
Male
Non-binary / third gender
Trans male
Trans female
Prefer to self-describe
Prefer not to say
Would you like to be contacted by us if we think you may be eligible for services?
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Yes
No
Would you like to be contacted by us if we think the person for whom you are taking this survey may be eligible for services?
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Yes
No
Please provide your email:
Please provide your phone number:
What services are you interested in?
Select all that apply
The following screen asks about your personal experiences. It asks about your sensory, psychological, emotional, and social experiences. Some of these questions may seem to relate directly to your experiences and others may not. Please read each question carefully and answer all questions.
Based on your experiences within the past year, please indicate how much you agree or disagree with each of the 12 statements by clicking the answer that best describes your experience.
0 - Definitely disagree
1 - Somewhat disagree
2 - Slightly disagree
3 - Not sure
4 - Slightly agree
5 - Somewhat agree
6 - Definitely agree
Please fill this out based on your experiences over the past year.
Please fill this out based on the experiences over the past year of the person you are referring/you are filling this out for
If you filled out the contact information above and would now like your client/referral to answer the questionnaire, please mark the check box below.
Who is answering this questionnaire?
My client/referral/child is answering this questionnaire
I am answering this questionnaire on behalf of my client/referral/child
I think that I have felt that there are odd or unusual things going on that I can't explain.
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Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I think that I might be able to predict the future.
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Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I may have felt that there could possibly be something interrupting or controlling my thoughts, feelings, or actions.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I have had the experience of doing something differently because of my superstitions.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I think that I may get confused at times whether something I experience or perceive may be real or may be just part of my imagination or dreams.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I have thought that it might be possible that other people can read my mind, or that I can read other people's minds.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I wonder if people may be planning to hurt me or even may be about to hurt me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I believe that I have special, natural, or supernatural gifts beyond my talents and natural strengths.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I think I might feel like my mind is "playing tricks" on me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I have had the experience of hearing faint or clear sounds of people or a person mumbling or talking when there is no one near me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I think that I may hear my own thoughts being said out loud.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
I have been concerned that I might be "going crazy".
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
When this happens, I feel frightened, or concerned, or it causes problems for me.
* must provide value
Definitely disagree
Somewhat disagree
Slightly disagree
Not sure
Slightly agree
Somewhat agree
Definitely agree
Prefer not to say
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Based on your responses to the screening questionnaire, it appears you are not eligible for services at the Strive for Wellness Clinic, serving those between the ages of 14-25. However, you are welcome to contact us if you’d like to speak further. If you'd like to read more information about our clinic, you can find more information on the following website . If interested in further conversation, please contact us by email at STRIVE@umbc.edu or by phone at 410-206-7415 If you or someone’s safety is at risk or emergency care is needed, dial 911 or go to your nearest hospital emergency room. You can also text "HOME” to the free Crisis Text Line (741741), or call the National Suicide Prevention Lifeline at 1-800-273-8255.
Based on your responses to the screening questionnaire, you currently may not benefit from further evaluation or services with our team. However, you are always welcome to contact us if you'd like to speak further, or take this screening questionnaire again to monitor your symptoms over time. If you'd like to read more information about our clinic, you can find more information on the following website . If interested in further conversation, please contact us by email at STRIVE@umbc.edu or by phone at 410-206-7415 If you or someone’s safety is at risk or emergency care is needed, dial 911 or go to your nearest hospital emergency room. You can also text "HOME” to the free Crisis Text Line (741741), or call the National Suicide Prevention Lifeline at 1-800-273-8255.
Based on your responses to the screening questionnaire, you may benefit from further evaluation or services with our team. If you provided contact information in your response and indicated you would like to hear from us, we will be reaching out to you shortly. If you'd like to read more information about our clinic, you can find more information on the following website . If interested in further conversation, please contact us by email at STRIVE@umbc.edu or by phone at 410-206-7415 If you or someone’s safety is at risk or emergency care is needed, dial 911 or go to your nearest hospital emergency room. You can also text "HOME” to the free Crisis Text Line (741741), or call the National Suicide Prevention Lifeline at 1-800-273-8255.