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Trusted Cares ® Forney Police Department

Officer Name/ID

Todays Date

MM slash DD slash YYYY

Person name/ID

Person Email

Person Phone

Questions

In the past couple of weeks I feel worse because my mood has been down or I'm not as interested in doing things.

Yes

No

In the past couple of weeks there has been a change in my sleep or appetite.

Yes

No

I can't stop feeling anxious or nervous or worrying about things.

Yes

No

I avoid situations or people because it is too stressful.

Yes

No

In the past year I drank alcohol or took drugs (including prescription drugs for pain, ADHD or sleep) more than a few times a month.

Yes

No

I have issues or stress in some area of my life, such as work, school or home because of one or more of the following: starting or finishing tasks, paying attention, missing details, organizing, forgetting things, losing things.

Yes

No

I have issues or stress in some area of my life, such as work, school or home because of one or more of the following: moving or fidgeting at the wrong times, talking at the wrong times, trouble waiting my turn.

Yes

No

I am worried or have difficulty in my daily life because of ongoing physical issues which have not gotten better over the last 6 months or more.

Yes

No

In the last year I've had thoughts or conversations about quitting or reducing my use of alcohol/ drugs (including prescription drugs for pain, ADHD or sleep).

Yes

No

In the last year I've felt remorse about the use of alcohol/ drugs (including prescription drugs for pain, ADHD or sleep).

Yes

No

In the last year something happened because of my use of alcohol/ drugs (including prescription drugs for pain, ADHD or sleep) that scared me or caused me concern.

Yes

No

Have you ever had at least 4 days in a row, where you were not your normal self and your mood was so good that people noticed or you felt like you could accomplish anything or you were indestructible or untouchable?

Yes

No

Have you ever had a time, lasting for at least 4 days in a row, where you were not your normal self and you felt irritated or restless and you wanted to argue or start fights but not for any specific reason?

Yes

No

In the last two weeks have you thought about death?

Yes

No

Were your thoughts about your own death?

Yes

No

Output - Results

Depression
- Risk of Depression

Depression
- Low Risk of Depression

Anxiety
- Risk of Anxiety

Anxiety
- Low Risk of Anxiety

ADHD
- Risk of ADHD

ADHD
- Low Risk of ADHD

Somatic Symptom Disorder >br>- Risk of Somatic Symptom Disorder

Somatic Symptom Disorder
- Low Risk of Somatic Symptom Disorder

Substance Use Disorder
- Risk of Substance Use Disorder

Substance Use Disorder
- Low Risk of Substance Use Disorder

Bipolar Disorder
- Risk of Bipolar Disorder

Bipolar Disorder - Low Risk of Bipolar Disorder

Suicidal
- Risk of Suicide

Suicidal
- Low Risk of Suicide

Do you want someone to follow up with this person?

Yes

Live phone is for partners only Monday - Thursday 9 am to 6 pm Friday 8 am to 5 pm Phone - 800-293-0145

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