Behavioral Assessment Tools: Which Screen to Hand

Behavioral assessment tools for intake

Screen	Measures	Age range	Items
PHQ-9	Depression	Adult clinics; PHQ-A for adolescents	9
GAD-7	Anxiety	Not published	7
AUDIT	Alcohol use	Not published	10
CRAFFT 2.1	Adolescent substance use	12 to 21	6, after opening questions
PC-PTSD-5	Probable PTSD	Not published	5, plus an exposure item
PCL-5	DSM-5 PTSD symptoms	Not published	20
ASRS v1.1 screener	Adult ADHD	18 and older	6 of 18
C-SSRS screener	Suicide risk	All ages	2 to 6
Vanderbilt (NICHQ)	Child ADHD	6 to 12	Not published
BASC-3	Child and adolescent behavior	Child and adolescent	Multiple forms

The same screens, with who completes each form, what it costs, and where the official form lives.

Screen	Completed by	Cost	Official source
PHQ-9	Self	Public domain	PHQ Screeners
GAD-7	Self	Public domain	PHQ Screeners
AUDIT	Clinician or self	No price listed	AUDIT form
CRAFFT 2.1	Patient or clinician	Free to use	CRAFFT
PC-PTSD-5	Respondent	Public domain	VA PC-PTSD-5
PCL-5	Self	Public domain	VA PCL-5
ASRS v1.1 screener	Self	Free; attribution required	NYU ASRS screener
C-SSRS screener	Interviewer	Free of charge in community and healthcare settings	Columbia protocol
Vanderbilt (NICHQ)	Not published	First edition free	NICHQ Vanderbilt
BASC-3	Parent, teacher, or self	Priced on the store	Pearson BASC-3

Where the publisher does not print a numeric age, treat the age as not published. Do not borrow an age from a different form. Get the items from the official source. Do not paste them into the chart, and do not build a handout that reprints them. A timed test battery is a different hour. You do not order it from these rows.

Fill this in for each screen you hand

Open the form the publisher still holds

PHQ-9 is the depression scale from the PHQ: nine items, each scored 0 to 3. GAD-7 is the anxiety measure: seven items, each scored 0 to 3. The instruction manual states that the PHQ family, including the GAD-7, is in the public domain, and that no permission is required to reproduce, translate, display, or distribute. PHQ Screeners is where you download them. The same manual describes the PHQ-A as a substantially modified version for adolescents. Use that form for an adolescent. Do not hand the adult PHQ-9 and call it the PHQ-A.

The manual does not print a numeric age band for the GAD-7. Treat that age as not published. Do not invent 12-plus or 18-plus because a different screen uses it.

The AUDIT is a 10-item screen the World Health Organization developed to identify hazardous and harmful drinking. The WHO guidelines are the developer manual, dated 18 November 2001. They do not list a purchase price. The NIDA PDF holds a clinician-administered version and a self-report version. Pick one, and write which one you used. A self-report total and an interview total are not the same administration.

CRAFFT is for adolescents aged 12 to 21. CRAFFT states that the tool is free to use, as a questionnaire the patient completes or as an interview you administer. The use page tells you to start with the opening frequency questions. If every opening answer is zero, you ask the CAR question only. If any alcohol, marijuana, or other-drug frequency is above zero, you ask the full set of six CRAFFT questions. Count those six. Do not reprint them.

For a child ADHD screen, NICHQ states that the Vanderbilt scales are used by health care professionals to help diagnose ADHD in children between 6 and 12. The first edition, published in 2002, is the free download on that page. The 3rd edition, dated 2019, is purchased from the American Academy of Pediatrics bookstore, which that page links. NICHQ does not print a single item count, and it does not name who completes the form. Do not guess either one.

The ASRS v1.1 screener is a 6-item self-report for adult ADHD symptoms in people aged 18 or older. NYU states that those six questions are a subset of the 18-question symptom checklist, and that the screener is freely available for clinical and non-clinical use, including commercial use, if you give attribution. No other modification is permitted, other than creating an electronic version. The copyright notice names New York University and the President and Fellows of Harvard College. Adler and Kessler created it. It is not a standalone diagnostic tool.

Keep the trauma screen and the suicide screen on their own forms

The VA PC-PTSD-5 page describes a 5-item screen for probable PTSD in primary care. It starts with a lifetime exposure item. If the person denies exposure, the screen is done and the score is 0. If they endorse exposure, they answer five yes-or-no questions about the past month. The measure is in the public domain and not copyrighted. The VA does not print a numeric age band on that page.

The PCL-5 is a different instrument: a 20-item self-report of the 20 DSM-5 PTSD symptoms, about 5 to 10 minutes, also public domain. Download it from the VA PCL-5 page. Score it on the PCL-5 score interpretation page. The cut points, the cluster counts, and the 10-point change live there. Do not apply them from memory at intake. Do not treat a PC-PTSD-5 yes-count as a PCL-5 total.

Columbia states that the C-SSRS is a series of plain-language questions anyone can ask, built to identify people of all ages at risk for suicide. On the about page, the shortest screeners run from two to six questions, and the number depends on the answers. That page states that the protocol and the training are available free of charge for use in community and healthcare settings, and in federally funded or nonprofit research. Open Columbia for the current questions. Read a positive on the C-SSRS page. Score a positive screen there. The two-to-six count is not the score.

When the question is drug use rather than alcohol, use the DAST screening tool and the form that page points to. Do not swap an AUDIT total for a drug screen.

Buy the form you do not hold

A paid inventory is still one of the behavioral assessment tools you might need. You buy it. You do not photocopy it.

Pearson describes BASC-3 as rating scales and forms that picture a child’s or adolescent’s behavior and emotions, including parent, teacher, and self forms. The store lists a price. That is the cost. The product page does not print a single item count. Do not guess one. If you do not hold the current license, you do not administer it, and you do not paste a sample report into the chart.

When the job is which brief measure to repeat across sessions, stop and use the scales for mental health matrix. Use that page for cadence, access, and the line you write beside a total. Keep the official form on the publisher page named above.

Write the name, the date, and the next step

Good care at intake is the form you can still find next month. Write the screen name, the version if there is one, who completed it, the date, and the total once you have scored it from the publisher instructions. Write the next step in the same line. A high total is a reason to ask more, not a diagnosis you have already made.

If the form name has to survive the hour, put that line in the session note the same day. The next clinician should not have to guess whether you handed the AUDIT interview or the self-report, or whether the adolescent form was the PHQ-A.

If the next hour needs a different screen, come back to these behavioral assessment tools and change the row. Do not keep a form that no longer matches the question in front of you.

Download the scales pack

The pack is the printable selection matrix for brief outpatient measures: use case, access, cadence, and one charting stem. Use it after you have named the screen from the tables above.

Educational resource for licensed clinicians. A screen is not a diagnosis, a testing battery, or a safety plan. Match the form to the person in front of you, and follow the publisher’s current terms before you administer or copy anything.

References

• Spitzer, R. L., Williams, J. B. W., & Kroenke, K. (n.d.). Instructions for Patient Health Questionnaire (PHQ) and GAD-7 measures.

• Patient Health Questionnaire screeners. (n.d.). Select a screener.

• World Health Organization. (2001). AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for use in primary care.

• National Institute on Drug Abuse. (n.d.). Alcohol Use Disorders Identification Test (AUDIT).

• CRAFFT. (n.d.). About the CRAFFT.

• CRAFFT. (n.d.). Use the CRAFFT.

• National Center for PTSD. (n.d.). Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). U.S. Department of Veterans Affairs.

• National Center for PTSD. (n.d.). PTSD Checklist for DSM-5 (PCL-5). U.S. Department of Veterans Affairs.

• NYU Langone Health. (n.d.). ASRS v1.1 6-question screener.

• The Columbia Lighthouse Project. (n.d.). About the protocol.

• The Columbia Lighthouse Project. (n.d.). The Columbia Protocol.

• National Institute for Children’s Health Quality. (n.d.). NICHQ Vanderbilt Assessment Scales.

• Pearson. (n.d.). BASC-3.