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* 1. Today's Date

Date

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* 2. First Name

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* 3. Last Name

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* 4. Date of Birth

Date

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* 5. Email

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* 6. SMS Text

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* 7. Has a healthcare or mental health provider ever told you that you have a mental health diagnosis?

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* 8. What diagnosis have you been given?

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* 9. Over the last two weeks have you experienced a reduction in interest or pleasure in doing things?

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* 10. Over the last two weeks have you felt down, depressed or hopeless?

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* 11. Over the last two weeks have you had thoughts that you would be better off dead or of hurting yourself in some way?

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* 12. How would you describe your stress level when you feel tense, nervous, anxious, or can’t sleep at night because their mind is troubled?

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* 13. Have you ever experienced traumatic events such as such as being in a serious accident, physical/emotional abuse, sexual assault or abuse, being in a war, seeing someone killed or assaulted, having a loved one die by suicide, being bullied/discriminated against, or other events/experiences that were distressing or disturbing to you?

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* 14. Have you had any changes in thinking, remembering, or making decisions?

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* 15. In the past month, have you felt worried, scared or confused that something may be wrong with your mind or memory?

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* 16. Has a healthcare provider ever told you or your family that when you were a child or adult that you had a developmental delay, disability, or brain injury that impacted your ability to think clearly (for example, traumatic brain injury, autism spectrum disorder, ADHD, learning disability)?

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* 17. In the past six months, how often have you used alcohol?

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* 18. In the past six months, how often have you used Nicotine products (Cigarette, vaping, chewing tobacco)?

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* 19. In the past six months, how often have you used prescription drugs not as prescribed (such as Pain medicines, ADHD medicines, and Sleeping pills)?

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* 20. In the past six months, how often have you used Marijuana?

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* 21. In the past six months, how often have you used other substances (such as cocaine, meth, heroin, hallucinogens, inhalants, and/or designer drugs)?

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* 22. Have you ever felt you ought to cut down on your drinking or drug use?

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* 23. Would you like to talk with someone about your substance use, especially if you are thinking of quitting or cutting back?

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