Adult Redcap copy

Confidential

Page 1

Adult

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Public reporting burden of this collection of information is estimated to average 60 minutes, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia
30333; ATTN: PRA (0920-24EG).
This survey asks about mental health and emotional well-being. If you answer that you have had suicidal thoughts or
behaviors, or purposely tried to hurt yourself, we may inform your doctor or other clinic staff. This would be to ensure
your safety and provide you with support and care.  By completing this survey, you accept and consent to this
protocol. If you have concerns or need immediate help, please tell the clinic staff.  Completing the survey is
voluntary. If you are not comfortable answering a question, just leave it blank.   
Today's Date

Timestamp

What is your date of birth?

Age (autocalculated): 

__________________________________

__________________________________

__________________________________

__________________________________

If you are under the age of 18, over the age of 26, or if you are filling this out for a child under the age of 18, please
request an alternative form from the project staff.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 2

Please answer the following questions about yourself.
What is your race and/or ethnicity? Select all that
apply.

American Indian or Alaska Native. For example,
Navajo Nation, Blackfeet Tribe of the Blackfeet
Indian Reservation of Montana, Native Village of
Barrow Inupiat Traditional Government, Nome Eskimo
Community, Aztec, Maya, etc.
Asian. For example, Chinese, Asian Indian,
Filipino, Vietnamese, Korean, Japanese, etc.
Black or African American. For example, African
American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc.
Hispanic or Latino. For example, Mexican, Puerto
Rican, Salvadoran, Cuban, Dominican, Guatemalan,
etc.
Middle Eastern or North African. For example,
Lebanese, Iranian, Egyptian, Syrian, Iraqi,
Israeli, etc.
Native Hawaiian or Pacific Islander. For example,
Native Hawaiian, Samoan, Chamorro, Tongan, Fijian,
Marshallese, etc.
White. For example, English, German, Irish,
Italian, Polish, Scottish, etc.

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep, or sleeping too
much

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself - or that you are a failure
or have let yourself or your family down

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things, such as reading the
newspaper or watching television

Not at all
Several days
More than half the days
Nearly every day

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 3

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

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead or of
hurting yourself in some way

Not at all
Several days
More than half the days
Nearly every day

If you checked off any problems, 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?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

During the past 12 months, how many times did you do
something to purposely hurt yourself without wanting
to die, such as cutting or burning yourself on
purpose?

0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

The next few questions are about thoughts of suicide.
At any time in the past 12 months, did you seriously
think about trying to kill yourself?

Yes
No

During the past 12 months, did you make any plans to
kill yourself?

Yes
No

During the past 12 months, did you try to kill
yourself?

Yes
No

During the past 12 months, did you get medical
attention from a doctor or other health professional
as a result of an attempt to kill yourself?

Yes
No

Did you stay in a hospital overnight or longer because
you tried to kill yourself?

Yes
No

If you ever feel that you need to talk to someone about mental health struggles, emotional distress, alcohol or drug
use concerns, you can call or text the 988 Suicide and Crisis Lifeline by dialing/texting 988. Counselors are available
to talk at any time of the day or night and they can give you information about services in your area. Services are
available in English and Spanish.
Please write down this number and website address.
988 (call or text)
https://988lifeline.org/
You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 4

Co-occurring Conditions
Have you EVER been told by a doctor or other health professional that you had:
Any type of anxiety disorder?
Some common types of anxiety disorders include
generalized anxiety disorder, social anxiety disorder,
panic disorder, and phobias.

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Any type of depression?

Yes
No

Some common types of depression include major
depression (or major depressive disorder), bipolar
depression, dysthymia, post-partum depression, and
seasonal affective disorder.
Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Autism or Autism Spectrum Disorder?

Yes
No

This includes diagnoses of Asperger's Disorder or
Pervasive Developmental Disorder (PDD).
Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Attention Deficit Disorder or
Attention-Deficit/Hyperactivity Disorder, that is, ADD
or ADHD?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Obsessive-compulsive disorder or OCD?

Yes
No

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 5

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Post-traumatic stress disorder or PTSD?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Substance use disorder?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Frequent or severe headaches, including migraine?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

A sleep disorder?

Yes
No

Examples of sleep disorders include sleep apnea,
insomnia, and narcolepsy.
Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Eating disorder?

Yes
No

Do you currently have the condition?

Yes
No

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 6

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Self-injurious behavior?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

A concussion or brain injury?

Yes
No

A concussion or brain injury is when a blow or jolt to
the head causes problems such as headaches, dizziness,
being dazed or confused, difficulty remembering or
concentrating, vomiting, blurred vision, changes in
mood or behavior, or being knocked out.
Have you EVER been told by a doctor or educator that you had:
Examples of educators are teachers and school nurses.
Behavioral or conduct problems?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Developmental delay?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Intellectual disability (formerly known as mental
retardation)?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 7

Speech disorder?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Language disorder?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Learning disability?

Yes
No

Do you currently have the condition?

Yes
No

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Has a doctor or other health care provider told you that you currently have:
Allergies (such as food, drug, insect, seasonal, or
other)?

Yes
No

Asthma?

Yes
No

Autoimmune disease (such as Type 1 Diabetes, Celiac,
or Juvenile Idiopathic Arthritis)?

Yes
No

Type 2 Diabetes?

Yes
No

Epilepsy or Seizure Disorder?

Yes
No

Have you ever shown extreme expression of anger, often
to the point of uncontrollable rage that is
disproportionate to the situation at hand?

Yes
No

Do you currently show extreme expression of anger?

Yes
No

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 8

Would you describe it as mild, moderate or severe?

Mild
Moderate
Severe

Have you ever had sensory processing problems?

Yes
No

For example, being hypersensitive (over-responsive) to
certain sensations (like certain lights, sounds,
touch, tastes, or smells) or hyposensitive
(under-responsive) and seek out sensory input, to the
point that it causes distress.

You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 9

Treatment for Tic Disorders and Related Conditions
The next questions ask about medications you may be taking for a tic disorder or related conditions.
Related conditions include things like ADHD, OCD, anxiety, depression, behavior issues, or other mental health
conditions.
Have you ever taken medication for a tic disorder or
related conditions?

Yes
No

At what age did you first start taking medication for
a tic disorder or related conditions?
Are you currently taking medication for a tic disorder
or related conditions?
What medications do you currently take for a tic
disorder or related conditions?

__________________________________
Yes
No

__________________________________

Please list all.
Who usually makes sure you take your medication for a
tic disorder or related conditions?

I do
A parent or guardian
Another family member or adult
Other person (Please specify relationship of other
person) ______

The next questions ask about other treatments for a tic disorder or related conditions.
Related conditions include things like ADHD, OCD, anxiety, depression, behavior issues, or other mental health
conditions.
Have you ever received comprehensive behavioral
intervention for tics (CBIT) or habit reversal therapy
for a tic disorder?

Yes
No
Don't know

Are you currently receiving comprehensive behavior
intervention for tics (CBIT) or habit reversal therapy
for a tic disorder?

Yes
No
Don't know

Have you ever received school-based behavioral
treatment, support, or accommodation for a tic
disorder or related conditions?

Yes
No
Don't know

Do not include CBIT or habit reversal therapy.
Are you currently receiving school-based behavioral
treatment, support, or accommodation for a tic
disorder or related conditions?
Do not include CBIT or habit reversal therapy.
Have you ever received behavioral treatment based
outside of school for a tic disorder or related
conditions?

Yes
No
Don't know
Not currently in school

Yes
No
Don't know

Do not include CBIT or habit reversal therapy.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 10

Are you currently receiving behavior treatment based
outside of school for a tic disorder or related
conditions?

Yes
No
Don't know

Do not include CBIT or habit reversal therapy.
Have you ever received any other treatment for a tic
disorder or related conditions?

Please specify any other treatment you have ever
received for a tic disorder or related conditions:
Are you currently receiving any other treatment for a
tic disorder or related conditions?

Please specify any other treatment you are currently
receiving for a tic disorder or related conditions:

Yes
No
Don't know

__________________________________
Yes
No
Don't know

__________________________________________

Overall, how satisfied are you with your tic disorder
treatment and management? 

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

In the past year, have you received any of the
following for any mental, emotional, or behavioral
problem, across settings (school, doctor's office)?

Social skills training
Cognitive behavioral therapy
Counseling (for example, talk therapy or
psychotherapy)
Other (Please specify) ______
None of these

Select all that apply.

You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 11

Healthcare Transition (from Pediatric to Adult Health Care)
SINCE TURNING 18, have you made the transfer to a
primary care provider who treats adults?

I already saw a primary care provider who treats
adults before I turned 18
Yes
No

How satisfied were you with the health care providers'
help to transfer your care to adult health care?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

Has a doctor or other health care provider talked with
you about the process of transferring to adult care?

Yes
No

Have any of your doctors or other health care
providers helped with finding a new primary care
provider who treats adults?

Yes, and I have seen a primary care provider who
treats adults
Yes, but I have not been able to see a primary
care provider who treats adults
No

Examples of assistance include suggesting names of
adult providers, making introductions, or sending a
letter to the new provider.
SINCE TURNING 18, have you needed to see a mental
health professional?

Yes
No

Mental health professionals include psychiatrists,
psychologists, psychiatric nurses, and clinical social
workers.
Did your doctors or other health care providers help
with finding mental health professionals who care for
adults?

Yes, and I have seen a mental health provider who
cares for adults
Yes, but I have not been able to see a mental
health provider who cares for adults
No

SINCE TURNING 18, have you needed to see a specialist
other than a mental health professional?

Yes
No

Examples of specialists include doctors like surgeons,
heart doctors, allergy doctors, skin doctors, and
others who specialize in one area of health care. Do
not include dentists or other oral health care
providers.
Did your doctors or other health care providers help
with finding specialists who care for adults (other
than mental health professionals)?

Yes, and I have seen a specialist who cares for
adults
Yes, but I have not been able to see a specialist
who cares for adults
No

SINCE TURNING 18, did you need to find a new health
professional for care related to your tic disorder? 

Yes
No

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 12

Did your doctors or other health care providers help
with finding a health professional who cares for
adults with tic disorders?
Examples of assistance include suggesting names of
adult providers, making introductions, or sending a
letter to the new provider.
SINCE TURNING 18, have you had any of the following
challenges in finding a health professional who treats
tic disorders in adults?
Select all that apply.
Providers in my area that treat tic disorders in
adults...

What other challenges (not listed above) have you
faced in finding a health professional who treats tic
disorders in adults?

Yes, and I have seen a health professional who
cares for adults with tic disorders
Yes, but I have not been able to see a health
professional who cares for adults with tic
disorders
No

are not accepting new patients
do not take my health insurance
do not have appointments in the next 6 months
do not have appointments that fit my schedule
do not offer in-person appointments
do not offer telehealth/virtual appointments
there are no providers that treat tic disorders in
adults in my area
I have had a different problem
I haven't had any problems finding a health
professional who treats tic disorders in adults

__________________________________________

You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 13

Employment and Service Use
LAST WEEK, did you work for pay at a job or business?

Yes
No

Did you have a job or business LAST WEEK, but were
temporarily absent due to illness, vacation, family or
maternity leave, or some other reason?

Yes
No

What is the MAIN reason you were not working for pay
at a job or business last week?

Unemployed, laid off, looking for work
Seasonal/contract work
Retired
Unable to work for health reasons/disabled
Taking care of house or family
Going to school
Working at a family-owned job or business not for
pay
Other

When was the last time you worked for pay at a job or
business, even if only for a few days?

Within the past 12 months
1-5 years ago
Over 5 years ago
Never worked

How many hours per week do you USUALLY work in total
at ALL jobs or businesses?
When you work do you USUALLY work 35 hours or more per
week in total at ALL jobs or businesses?
During the past 12 months, about how many days of work
did you miss because you had an illness, injury, or
disability?

__________________________________
Yes
No

__________________________________

Do not include family or paternity/maternity leave.

Last year, how much was paid out-of-pocket for your
OWN medical care, such as copays for doctor and
dentist visits, diagnostic tests, prescription
medicine, glasses and contacts, and medical
supplies? 
Include any amount paid out-of-pocket on your behalf
by anyone in this household.
Last year, how much was paid out-of-pocket for your
non-prescription healthcare products such as vitamins,
allergy and cold medicine, pain relievers, quit
smoking aids, AND anything else not yet reported?
Include any amount paid out-of-pocket on your behalf
by anyone in this household.

03/04/2025 5:04pm

$0 (No medical or health-related expenses)
$1-$249
$250-$499
$500-$999
$1,000-$5,000
More than $5,000

$0 (No medical or health-related expenses)
$1-$249
$250-$499
$500-$999
$1,000-$5,000
More than $5,000

projectredcap.org

Confidential
Page 14

Last year, how much was paid out-of-pocket for your
OWN mental health care, including copays for doctor
visits, prescription medicine, and therapy or
counseling?
Include any amount paid out-of-pocket on your behalf
by anyone in this household.

$0 (No medical or health-related expenses)
$1-$249
$250-$499
$500-$999
$1,000-$5,000
More than $5,000

During the past 12 months, have you DELAYED getting
counseling or therapy from a mental health
professional because of the cost?

Yes
No

During the past 12 months, was there any time when you
needed counseling or therapy from a mental health
professional, but DID NOT GET IT because of the cost?

Yes
No

During the past 12 months, have you DELAYED getting
care from a mental health professional because you
couldn't get an appointment?

Yes
No

If yes, how long was the delay?

Less than 3 months
3-6 months
7-12 months
More than 12 months

The next questions are about your medical bills. Include bills for doctors, dentists, hospitals, therapists, medication,
equipment, and nursing home or home care.
In the past 12 months, did you have problems paying or
were unable to pay any medical bills?

Yes
No

Do you currently have any medical bills that you are
unable to pay at all?

Yes
No

If you get sick or have an accident, how worried are
you that you will be able to pay your medical bills? 

Very worried
Somewhat worried
Not at all worried

During the past 12 months, have you DELAYED getting
medical care because of the cost?

Yes
No

During the past 12 months, was there any time when you
needed medical care, but DID NOT GET IT because of the
cost?

Yes
No

At any time in the past 12 months, did you take
prescription medication?

Yes
No

During the past 12 months, were any of the following true for you?
You skipped medication doses to save money.

Yes
No

You took less medication to save money.

Yes
No

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 15

You DELAYED filling a prescription to save money.

Yes
No

During the past 12 months, was there any time when you
needed prescription medication, but DID NOT GET IT
because of the cost?

Yes
No

During the past 12 months, how many times have you
gone to a hospital emergency room about your health?
During the past 12 months, have you been hospitalized
overnight?

__________________________________
Yes
No

You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 16

Additional Questions About You
Which of the following best represents how you think
of yourself?

Gay (lesbian or gay)
Straight, this is not gay (or lesbian or gay)
Bisexual
Something else
I don't know the answer

What is your sex?

Male
Female

What is the HIGHEST level of school you have completed
or the highest degree you have received?

Never attended/kindergarten only
Grade 1-11
12th grade, no diploma
GED or equivalent
High school graduate
Some college, no degree
Associate degree: occupational, technical, or
vocational program
Associate degree: academic program
Bachelor's degree (Example: BA, AB, BS, BBA)
Master's degree (Example: MA, MS, MEng, MEd, MBA)
Professional school degree (Example: MD, DDS, DVM,
JD)
Doctoral degree (Example: PhD, EdD)

Are you now married, living with a partner together
as an unmarried couple, or neither?

Married
Living with a partner together as an unmarried
couple
Neither

The next questions are about health insurance. Include health insurance obtained through employment or purchased
directly as well as government programs like Medicare, Medicaid, and the Children's Health Insurance Program that
provide medical care or help pay medical bills.
Are you covered by any kind of health insurance or
some other kind of health care plan?

Yes
No

What kinds of health insurance or health care coverage
do you have?

Private health insurance
Medicare
Medigap
Medicaid
Children's Health Insurance Program (CHIP)
Military related health care: TRICARE (CHAMPUS) /
VA health care / CHAMP-VA
Indian Health Service
State-sponsored health plan
Other government program
No coverage of any type

Select all that apply.

Health insurance plans are usually obtained in one
person's name even if other family members are covered
by that plan. That person is called the policyholder.
Are you the policyholder for your health insurance
plan?

Yes
No

How are you related to the policyholder for your
health insurance? Are you the policyholder's child,
spouse, former spouse, or are you related in some
other way?

Child
Spouse
Former spouse
Some other relationship

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 17

The following questions are about the address where you currently live.
What is your current street address?
Example: 123 Main Street
What is the apartment or unit number (skip if none)?
Example: Apt. 5a
In what city do you currently live?

03/04/2025 5:04pm

__________________________________________

__________________________________

__________________________________

projectredcap.org

Confidential
Page 18

In what state do you currently live?

Specify other place (not US state) you live

What is your current zip code (for address above)?

03/04/2025 5:04pm

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other (Please specify)

__________________________________

__________________________________

projectredcap.org

Confidential
Page 19

How many people are living or staying at this address?

__________________________________

Include everyone who usually lives or stays at this
address. Do NOT include anyone who is living somewhere
else for more than two months, such as a college
student living away or someone in the Armed Forces on
deployment.
What is your best estimate of your total family income
from all sources, before taxes, in the last year? 

< $15,000
$15,000-$24,999
$25,000-49,999
$50,000-74,999
$75,000-99,999
$100,000-149,999
$150,000-199,999
$200,000 or higher

Some people who are deaf or have serious difficulty
hearing use assistive devices to communicate by phone.
Are you deaf or do you have serious difficulty
hearing?

Yes
No

Are you blind or do you have serious difficulty
seeing, even when wearing glasses?

Yes
No

Because of a physical, mental, or emotional condition,
do you have serious difficulty concentrating,
remembering, or making decisions?

Yes
No

Do you have serious difficulty walking or climbing
stairs?

Yes
No

Do you have difficulty dressing or bathing?

Yes
No

Because of a physical, mental, or emotional condition,
do you have difficulty doing errands alone such as
visiting a doctor's office or shopping?

Yes
No

You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 20

Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge

Not at all
Several days
More than half the days
Nearly every day

Not being able to stop or control worrying

Not at all
Several days
More than half the days
Nearly every day

Worrying too much about different things

Not at all
Several days
More than half the days
Nearly every day

Trouble relaxing

Not at all
Several days
More than half the days
Nearly every day

Being so restless that it is hard to sit still

Not at all
Several days
More than half the days
Nearly every day

Becoming easily annoyed or irritable

Not at all
Several days
More than half the days
Nearly every day

Feeling afraid as if something awful might happen

Not at all
Several days
More than half the days
Nearly every day

If you checked off any problems, 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?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Did anyone help you complete this survey?

Yes, someone helped me, but I completed most of
the survey on my own.
Yes, someone helped me with all or most of the
survey.
No, I completed the survey on my own.

If you are interested in receiving project updates in
the future, please enter your email address.  

__________________________________

You may decline to be re-contacted now or at any time
in the future.
You skipped one or more questions on this page. Please review and complete the question(s) before going to the
next page. If you intentionally skipped the question(s), you can go to the next page.

03/04/2025 5:04pm

projectredcap.org

Confidential

Page 1

ASQ
Please complete the survey below.Thank you!

Medical Record Number

Timestamp

__________________________________

__________________________________

Please ask the following questions only for those ages 9 and up.
Note to person administering the ASQ: Please provide the following information to the respondent before asking the
questions.
This survey asks about mental health and emotional well-being. If you answer that you have had suicidal thoughts or
behaviors, or purposely tried to hurt yourself, we may inform your doctor or other clinic staff. This would be to ensure
your safety and provide you with support and care.
By completing this survey, you accept and consent to this protocol. If you have concerns or need immediate help,
please tell the clinic staff.
1)  In the past few weeks, have you wished you were
dead?

Yes
No
Refused to answer

2) In the past few weeks, have you felt that you or
your family would be better off if you were dead?

Yes
No
Refused to answer

3) In the past week, have you been having thoughts
about killing yourself?

Yes
No
Refused to answer

4) Have you ever tried to kill yourself?

Yes
No
Refused to answer

4a) How?
__________________________________________
4b) When?
__________________________________________
The patient answered "No" to questions 1 through 4; therefore, screening is complete, and it is not necessary to ask
question #5. No intervention is necessary; however, clinical judgment can always override a negative screen.
Do you want to ask the patient question #5 (Are you
having thoughts of killing yourself right now?) or
finish the ASQ?

Ask question #5
Finish the ASQ

This patient is considered a positive screen. Ask question #5 to assess acuity.
5) Are you having thoughts of killing yourself right
now?

03/04/2025 5:04pm

Yes
No

projectredcap.org

Confidential
Page 2

5b) Please describe:

__________________________________

Patient is acute positive screen (imminent risk identified)
Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety.
Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician responsible for patient's
care.
Provide resources to all patients: 988 Suicide and Crisis Lifeline, 988 (call, text), 
https://988lifeline.org/
Patient is non-acute positive screen (potential risk identified).
Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. If a
patient (or parent/guardian) refuses the brief assessment, this should be treated as an "against medical advice"
(AMA) discharge.
Alert physician or clinician responsible for patient's care.
Provide resources to all patients: 988 Suicide and Crisis Lifeline, 988 (call, text), 
https://988lifeline.org/
Initials of person (staff/professional) completing ASQ

Optional: Provide any comments on clinical information
entered on this form. Please do not use any patient
identifiers.

__________________________________

__________________________________________

Overview of ASQ - this information is included above, within skip logic, and only included here for reference.
If patient answers "No" to all questions 1 through 4, screening is complete (not necessary to ask question #5). No
intervention is necessary (*Note: Clinical judgment can always override a negative screen).
If patient answers "Yes" to any of questions 1 through 4, or refuses to answer, they are considered a positive screen.
Ask question #5 to assess acuity.
"Yes" to question #5 = acute positive screen (imminent risk identified)
Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety.
Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician responsible for patient's
care.
"No" to question #5 (but "Yes" or "Refused" to one of questions 1-4) = non-acute positive screen (potential risk
identified)
Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. If a
patient (or parent/guardian) refuses the brief assessment, this should be treated as an "against medical advice"
(AMA) discharge.
Alert physician or clinician responsible for patient's care.
Provide Resources to All Patients: 
•988 Suicide and Crisis Lifeline, Call or Text 988
•Visit https://988lifeline.org to chat

03/04/2025 5:04pm

projectredcap.org

Confidential

Page 1

YGTSS
Please complete the survey below.Thank you!

Medical Record Number

Timestamp

__________________________________

__________________________________

This instrument to be completed by trained professional.
Motor Tics
Age of first motor tics, in years

Describe first motor tic:

Was tic onset sudden or gradual?

Age of worst motor tics, in years?

__________________________________

__________________________________

__________________________________

__________________________________

Motor Tic Symptom Checklist
Please select if the patient currently (during the past week) has each tic OR if they ever (but not currently) had the
tic. State age of onset (in years) if patient has had this behavior.
The patient has experienced, or others have noticed, involuntary and apparently purposeless bouts of:
eye movements
eye blinking, squinting, a quick turning of the eyes,
rolling of the eyes to one side, or opening eyes wide
very briefly.
What was the age of onset of this behavior?

eye gestures such as looking surprised or quizzical,
or looking to one side for a brief period of time, as
if s/he heard a noise.
What was the age of onset of this behavior?

nose, mouth, tongue movements, or facial grimacing
nose twitching, biting the tongue, chewing on the lip
or licking the lip, lip pouting, teeth baring, or
teeth grinding.
What was the age of onset of this behavior?

03/04/2025 5:04pm

Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________

projectredcap.org

Confidential
Page 2

broadening the nostrils as if smelling something,
smiling, or other gestures involving the mouth,
holding funny expressions, or sticking out the tongue.
What was the age of onset of this behavior?

head jerks/movements
touching the shoulder with the chin or lifting the
chin up.
What was the age of onset of this behavior?

throwing the head back, as if to get hair out of the
eyes.
What was the age of onset of this behavior?

shoulder jerks/movements
jerking a shoulder.
What was the age of onset of this behavior?

shrugging the shoulder as if to say "I don't know."

What was the age of onset of this behavior?

arm or hand movements
quickly flexing the arms or extending them, nail
biting, poking with fingers, or popping knuckles.
What was the age of onset of this behavior?

passing hand through the hair in a combing like
fashion, or touching objects or others, pinching, or
counting with fingers for no purpose, or writing
tics, such as writing over and over the same letter
or word, or pulling back on the pencil while writing.
What was the age of onset of this behavior?

leg, foot, or toe movements
kicking, skipping, knee-bending, flexing or extension
of the ankles; shaking, stomping or tapping the foot.

03/04/2025 5:04pm

Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

projectredcap.org

Confidential
Page 3

What was the age of onset of this behavior?

taking a step forward and two steps backward,
squatting, or deep knee-bending.
What was the age of onset of this behavior?

abdominal/trunk/pelvis movements
tensing the abdomen, tensing the buttocks.
What was the age of onset of this behavior?

other simple motor tics.

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

Please write example(s):
__________________________________________
What was the age of onset of this behavior?

Other complex motor tics
touching
What was the age of onset of this behavior?

tapping

What was the age of onset of this behavior?

picking

What was the age of onset of this behavior?

evening-up

What was the age of onset of this behavior?

reckless behaviors

What was the age of onset of this behavior?

03/04/2025 5:04pm

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________

projectredcap.org

Confidential
Page 4

stimulus-dependent tics (a tic which follows, for
example, hearing a particular word or phrase, seeing a
specific object, smelling a particular odor).
What was the age of onset of this behavior?

Please write example(s):

rude/obscene gestures; obscene finger/hand gestures.

What was the age of onset of this behavior?

unusual postures.

What was the age of onset of this behavior?

bending or gyrating, such as bending over.

What was the age of onset of this behavior?

rotating or spinning on one foot.

What was the age of onset of this behavior?

copying the action of another (echopraxia)

What was the age of onset of this behavior?

sudden tic-like impulsive behaviors.

What was the age of onset of this behavior?

Current
Ever

__________________________________

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________

Please describe this behavior.
__________________________________________
tic-like behaviors that could injure/mutilate others.

What was the age of onset of this behavior?

03/04/2025 5:04pm

Current
Ever

__________________________________

projectredcap.org

Confidential
Page 5

Please describe this behavior.
__________________________________________
self-injurious tic-like behavior(s).

What was the age of onset of this behavior?

Please describe this behavior.

other involuntary and apparently purposeless motor
tics (that do not fit in any previous categories).
Please describe any other patterns or sequences of
motor tic behaviors:

Current
Ever

__________________________________

__________________________________

__________________________________________

Phonic (Vocal) Tics
Age of first vocal tics, in years

Describe first vocal tic:

Was tic onset sudden or gradual?

Age of worst vocal tics, in years

__________________________________

__________________________________

__________________________________

__________________________________

Phonic Tic Symptom Checklist
Please select if the patient currently (during the past week) has each tic OR if they ever (but not currently) had the
tic. State age of onset (in years) if patient has had this behavior.
The patient has experienced, or others have noticed, involuntary and apparently purposeless bouts of:
coughing.

What was the age of onset of this behavior?

throat clearing.

What was the age of onset of this behavior?

sniffing.

03/04/2025 5:04pm

Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

projectredcap.org

Confidential
Page 6

What was the age of onset of this behavior?

whistling.

What was the age of onset of this behavior?

animal or bird noises.

What was the age of onset of this behavior?

other simple phonic tics.

What was the age of onset of this behavior?

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________

Please list:
__________________________________________
syllables.

What was the age of onset of this behavior?

Current
Ever

__________________________________

Please list:
__________________________________________
words.

What was the age of onset of this behavior?

Current
Ever

__________________________________

Please list:
__________________________________________
rude or obscene words or phrases.

What was the age of onset of this behavior?

Current
Ever

__________________________________

Please list:
__________________________________________

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 7

repeating what someone else said, either sounds,
single words or sentences. Perhaps repeating what's
said on TV (echolalia).
What was the age of onset of this behavior?

repeating something the patient said over and over
again (palilalia).
What was the age of onset of this behavior?

other tic-like speech problems, such as sudden changes
in volume or pitch.
What was the age of onset of this behavior?

Current
Ever

__________________________________
Current
Ever

__________________________________
Current
Ever

__________________________________

Please describe:
__________________________________________
Describe any other patterns or sequences of phonic tic
behaviors:

What was the age of onset of this behavior?

03/04/2025 5:04pm

__________________________________________

__________________________________

projectredcap.org

Confidential
Page 8

Severity Ratings: Number (Past 7-10 days)
Current Motor Number
Current Phonic Number
______ ______
Rating Scale
(0) None (no tics) 
(1) Single tic
(2) Multiple discrete tics (2-5)
(3) Multiple discrete tics (>5) 
(4) Multiple discrete tics plus at least one
orchestrated pattern of multiple simultaneous or
sequential tics where it is difficult to distinguish
discrete tics. 
(5) Multiple discrete tics plus several (>2)
orchestrated paroxysms of multiple simultaneous or
sequential tics where it is difficult to distinguish
discrete tics. 

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 9

Severity Ratings: Frequency (Past 7-10 days)
Current Motor Frequency
Current Phonic Frequency
______ ______
Rating Scale
(0) None: No evidence of specific tic behaviors. 
(1) Rarely: Specific tic behaviors have been present
during previous week. These behaviors occur
infrequently, often not on a daily basis. If bouts of
tics occur, they are brief and uncommon.
(2) Occasionally: Specific tic behaviors are usually
present on a daily basis, but there are long tic-free
intervals during the day. Bouts of tics may occur on
occasion and are not sustained for more than a few
minutes at a time. 
(3) Frequently: Specific tic behaviors are present on
a daily basis. Tic free intervals as long as 3 hours
are not uncommon. Bouts of tics occur regularly but
may be limited to a single setting.
(4) Almost Always: Specific tic behaviors are present
virtually every waking hour of every day, and periods
of sustained tic behaviors occur regularly. Bouts of
tics are common and are not limited to a single
setting.
(5) Always: Specific tic behaviors are present
virtually all the time. Tic free intervals are
difficult to identify and do not last more than 5 to
10 minutes at most.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 10

Severity Ratings: Intensity (Past 7-10 days)
Current Motor Intensity
Current Phonic Intensity
______ ______
Rating Scale
(0) Absent: Tics are not present at all
(1) Minimal: Tics are not visible or audible (based
solely on patient's private experience) or tics are
less forceful than comparable voluntary actions and
are typically not noticed because of their intensity.

(2) Mild: Tics are not more forceful than comparable
voluntary actions or utterances and are typically not
noticed because of their intensity.

(3) Moderate: Tics are more forceful than comparable
voluntary actions, but are not outside the range of
normal expression for comparable voluntary actions or
utterances. They may call attention to the individual
because of their forceful character.

(4)  Marked: Tics are more forceful than comparable
voluntary actions or utterances and typically have an
"exaggerated" character. Such tics frequently call
attention to the individual because of their forceful
and exaggerated character.

(5) Severe: Tics are extremely forceful and
exaggerated in expression. These tics call attention
to the individual and may result in risk of physical
injury (accidental, provoked, or self-inflicted)
because of their forceful expression.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 11

Severity Ratings: Complexity (Past 7-10 days)
Current Motor Complexity
Current Phonic Complexity
______ ______
Rating Scale
(0) None: Tics are not present OR if present, all
tics are clearly "simple" (sudden, brief, purposeless)
in character.

(1) Borderline: Some tics are not clearly "simple" in
character.

(2) Mild: Some tics are clearly "complex" (purposeful
in appearance) and mimic brief "automatic" behaviors,
such as grooming, syllables, or brief meaningful
utterances such as "ah huh", or "hi", that could be
readily camouflaged.

(3) Moderate: Some tics are more "complex" (more
purposeful and sustained in appearance) and may occur
in orchestrated bouts that would be difficult to
camouflage, but could be rationalized or "explained"
as normal behavior or speech (picking, tapping, saying
"you bet" or "honey", brief echolalia).

(4) Marked: Some tics are very "complex" in character
and tend to occur in sustained orchestrated bouts that
would be difficult to camouflage and could not be
easily rationalized as normal behavior or speech
because of their duration and/or their unusual,
inappropriate, bizarre or obscene character (a lengthy
facial contortion, touching genitals, echolalia,
speech atypicalities, longer bouts of saying "what do
you mean" repeatedly or saying "fu" or "sh").

(5)  Severe: Some tics involve lengthy bouts of
orchestrated behavior or speech that would be
impossible to camouflage or successfully rationalize
as normal because of their duration and/or extremely
unusual, inappropriate, bizarre or obscene character
(lengthy displays or utterances often involving
copropraxia, self-abusive behavior, or coprolalia).

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 12

Severity Ratings: Interference (Past 7-10 days)
Current Motor Interference
Current Phonic Interference
______ ______
Rating Scale
(0) None: This means there are no tics present at
all.

(1) Minimal: When tics are present, they do not
interrupt the flow of behavior or speech.

(2) Mild: When tics are present, they occasionally
interrupt the flow of behavior or speech.

(3) Moderate: When tics are present, they frequently
interrupt the flow of behavior or speech.

(4) Marked: When tics are present, they frequently
interrupt the flow of behavior or speech, and they
occasionally disrupt intended action or communication.

(5) Severe: When tics are present, they frequently
disrupt intended action or communication.

03/04/2025 5:04pm

projectredcap.org

Confidential
Page 13

Severity Ratings: Impairment (Past 7-10 days)
Current Motor Impairment
Current Phonic Impairment
______ ______
Rating Scale
(0) None

(10) Minimal: Tics associated with subtle
difficulties in self-esteem, family life, social
acceptance or school/job functioning (infrequent upset
or concern about tics vis a vis the future, periodic,
slight increase in family tensions because of tics;
friend or acquaintances may occasionally notice or
comment about tics in an upsetting way.

(20) Mild: Tics associated with minor difficulties in
self-esteem, family life, social acceptance, or
school/job functioning.

(30) Moderate: Tics associated with some clear
problems in self-esteem, family life, social
acceptance, or school/job functioning (episodes of
dysphoria, periodic distress and upheaval in the
family, frequent teasing by peers or episodic social
avoidance, periodic interference in school/job
performance because of tics).

(40) Marked: Tics associated with major difficulties
in self-esteem, family life, social acceptance, or
school/job functioning.

(50) Severe: Tics associated with extreme
difficulties in self-esteem, family life, social
acceptance, or school/job functioning (severe
depression with suicidal ideation, disruption of the
family [separation/divorce, residential placement],
disruption of social ties, severely restricted life
because of social stigma and social avoidance, removal
from school/job).
Initials of person completing this form.

Optional: Provide any comments on clinical information
entered on this form. Please do not use any patient
identifiers.

03/04/2025 5:04pm

__________________________________

__________________________________________

projectredcap.org

Confidential
Page 14

For the person conducting the assessment: How familiar
are you with this individual (being assessed with
YGTSS)?

03/04/2025 5:04pm

Not familiar (for example: this was my first
encounter with this individual, or previous
encounters were very brief)
Somewhat familiar (for example: I have interacted
with this individual on more than one occasion and
for more than just a brief encounter)
Very familiar (I have interacted with this
individual on several occasions AND am very
familiar with their tic symptoms)

projectredcap.org