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Trusted Cares® – Rowlett PD
Trusted Cares ® Rowlett Police
Officer Name/ID
Todays Date
MM slash DD slash YYYY
Person name/ID
Is the person Under 18?
Yes
No
Parents Name
(Required)
First
Last
Parents Email
(Required)
Parents Phone
(Required)
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
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Source
Connector Field
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Agency
Do you want someone to follow up with this person?
Yes
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Status
Agency Review
Funding Not Requested
Funding Request
Approved
Rejected
