Participant Screening

Participant Screening

Welcome to the Registration Portal for Mountain Strong WNC. We’re glad that you’ll be participating with us in our programs and are excited to help you register! This process will take aproximately 30 minutes to complete. During this screening, you will answer some questions about yourself, your experiences and your beliefs.


Contact and Personal Information
The following information is required for all participants. All screening forms must be completed prior to participating in any programs. Please contact us if you have any questions.

Please make sure this is a valid email where we can reach you.
How many people live in your home?
Are you a veteran?
 
Please enter your age as a number
  
Who referred you to us?

Tuberculosis Screening
To help in the prevention of airborne infectious diseases, please respond to the following questions about your health.

Have you had an unexplained cough for greater than 3 weeks in which you cough up from your lungs a thick yellowish or greenish phlegm/mucous? (NOTE: Answer yes only if the mucous production is generally as bad in the afternoon and evening as it is in the morning.)
 
Have you experienced any Unexplained Weight Loss?
 
During the last 14 days or longer, have you woken up nearly every night with night sweats that drench your bed clothes and sheets? (NOTE: Answer yes only if these are not caused by hormonal problems or drug withdrawal.)
 

Risk Factors
For the next two questions, please select any of the risk factors that apply to you.


GAIN Short Screening
The following questions are about common psychological, behavioral, and personal problems.

These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can’t go on.

  1. Read the introductory paragraph.
  2. Please read each item carefully to avoid any misunderstanding.
  3. Answer as accurately as you can. If you have trouble remembering the last time something happened, use your very best estimate.
  4. Choose the response that comes closest to how you feel.
  5. Don’t forget to read the stem at the beginning of each section (e.g., “When was the last time…”). If you are having trouble understanding a question, repeat it several times.

When was the LAST TIME that you had significant problems… with feeling very trapped, lonely, sad, blue, depressed, or hopeless?
When was the LAST TIME that you had significant problems...with sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?
When was the LAST TIME that you had significant problems...with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?
When was the LAST TIME that you had significant problems...with becoming very distressed and upset when something reminded you of the past?
When was the LAST TIME that you had significant problems...with thinking about ending your life or committing suicide?
When was the LAST TIME that you... Lied or conned to get things you wanted or to avoid having to do something TWO OR MORE TIMES?
When was the LAST TIME that you had significant problems...had a hard time listening to instruction at school, work, or home?
When was the LAST TIME that you... Had a hard time paying attention at school, work, or home TWO OR MORE TIMES?
When was the LAST TIME that you... Were a bully or threatened other people TWO OR MORE TIMES?
When was the LAST TIME that you... Started physical fights with other people TWO OR MORE TIMES?
When was the LAST TIME that... you used alcohol or other drugs weekly or more often?
When was the LAST TIME that... you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs?
When was the LAST TIME that... you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?
When was the LAST TIME that... your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home. or social events?
When was the LAST TIME that... you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?
When was the LAST TIME that you... had a disagreement in which you pushed, grabbed, or shoved someone?
When was the LAST TIME that you... took something from a store without paying for it?
When was the LAST TIME that you... sold, distributed, or helped to make illegal drugs?
When was the last time that you drove a vehicle while under the influence of alcohol or illegal drugs?
When was the LAST TIME that... purposely damaged or destroyed property that did not belong to you?
Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with?

Survey Questions
The survey section asks questions and collects answers from each participant that are required for participation. The information collected will be used confidentially.

Do your parents/family disapprove of you using alcohol?
 
Do your parents/family disapprove of you using tobacco?
 
Do your parents/family disapprove of you using marijuana?
 
Do your parents/family disapprove of you using prescription drugs if they belong to someone else or if they are yours and NOT being taken as prescribed?
 
Do your parents/family disapprove of you using any other drugs?
 
Do you believe use of alcohol puts you at a higher risk for harm?
 
Do you believe use of tobacco puts you at a higher risk for harm?
 
Do you believe use of marijuana puts you at a higher risk for harm?
 
Do you believe misuse of prescription drugs puts you at a higher risk for harm?
 
Do you believe use of any other drugs puts you at a higher risk for harm?
 
What is your attitude toward people who use alcohol?
What is your attitude toward people who use tobacco?
What is your attitude toward people who use marijuana?
What is your attitude toward people who use prescription drugs?
What is your attitude toward people who use other drugs?
Would it be easy for you to get alcohol if you wanted it?
 
Would it be easy for you to get tobacco if you wanted it?
 
Would it be easy for you to get marijuana if you wanted it?
 
Would it be easy for you to get prescription drugs if you wanted it?
 
Would it be easy for you to get other drugs if you wanted it?
 

For the following questions, if you have never tried a substance type: "never".

How old were you when you first tried tobacco?
How old were you when you first tried alcohol?
How old were you when you first tried marijuana?
How old were you when you first tried prescription drugs?
How old were you when you first tried any other drugs?

You are about to complete this screening and submit your responses. Please look over any responses you wish to edit now BEFORE you submit. You will not have an opportunity to make any changes.