Free tool · Scored assessments

Psych Scored Assessments.

Four behavioral-health instruments in one place. Toggle between the PHQ-9 (depression), GAD-7 (anxiety), C-SSRS (Columbia suicide-risk screen), and AIMS (abnormal involuntary movement scale for tardive dyskinesia). Score each, get the total, the severity band or risk level, and the safety flags. All are free, public-domain or licence-free instruments — each keeps its own scoring rules and citations.

Over the last 2 weeks, how often bothered by…

0 = Not at all · 1 = Several days · 2 = More than half the days · 3 = Nearly every day.

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

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

8. 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

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

0/ 27 · 0 of 9 items scored

Answer all nine items to see the score.

Disclaimer: Educational screening tool only — not a diagnosis and not a substitute for clinical evaluation. The PHQ-9 supports, but does not replace, a clinician’s assessment, and a positive item 9 requires a direct safety evaluation per your protocol. Enter de-identified values only; nothing is stored or transmitted. The PHQ was developed by Drs. Spitzer, Williams, Kroenke and colleagues with an educational grant from Pfizer; no permission is required to reproduce, translate, display, or distribute it.

References

Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. PMID: 11556941. (Items, 0–3 scoring, severity bands, ≥10 cut-point.)
PHQ / PRIME-MD instruments are free for use without permission. See the PHQ Screeners site (Pfizer). (Public-domain status.)
If you or someone you are caring for is in crisis, the 988 Suicide & Crisis Lifeline (US) is available 24/7 by call or text to 988.

Items and bands transcribed from the validated PHQ-9. Clinical use is individualized by the care team.

Over the last 2 weeks, how often bothered by…

0 = Not at all · 1 = Several days · 2 = More than half the days · 3 = Nearly every day.

1. Feeling nervous, anxious, or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it is hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid, as if something awful might happen

0/ 21 · 0 of 7 items scored

Answer all seven items to see the score.

Disclaimer: Educational screening tool only — not a diagnosis and not a substitute for clinical evaluation. The GAD-7 supports, but does not replace, a clinician’s assessment. Enter de-identified values only; nothing is stored or transmitted. The PHQ/GAD instruments are free to use without permission.

References

Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097. PMID: 16717171. (Items, 0–3 scoring, severity bands, ≥10 cut-point.)
PHQ/GAD instruments are free for use without permission (Pfizer / PHQ Screeners).

Items and bands transcribed from the validated GAD-7. Clinical use is individualized by the care team.

Columbia screener — Screen Version, Recent

Ask the questions in bold exactly as written. Questions 1–5 ask about the past month; question 6 asks about lifetime behaviour, then the past 3 months.

Have you wished you were dead or wished you could go to sleep and not wake up?past month

Have you actually had any thoughts of killing yourself?past month

If Yes → questions 3, 4, 5 and 6. If No → skip to question 6.

Have you been thinking about how you might do this?past month

e.g. "I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it… and I would never go through with it."

Have you had these thoughts and had some intention of acting on them?past month

as opposed to "I have the thoughts but I definitely will not do anything about them."

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?past month

Have you ever done anything, started to do anything, or prepared to do anything to end your life?lifetime

Examples: collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

Answer the questions above to see the risk triage.

How the screen triages [2][3]

Highest "Yes"	Risk	Typical response (confirm with your protocol)
Q1 and/or Q2 only	Low	Behavioral-health referral; share with provider; reassess.
Q3	Moderate	Behavioral-health referral / consult; safety review; don't leave alone if concerned.
Q4, Q5, or any Q6 behavior	High	Immediate safety: do not leave the patient alone, remove means, urgent behavioral-health / provider evaluation, suicide precautions per protocol.

Within the High band, intent (Q4), a plan (Q5), or any suicidal behavior within the past 3 months (Q6) are the most acute and call for immediate suicide precautions. A positive behavior on Q6 — even lifetime — is treated as a high-risk flag here. Columbia publishes several setting-specific triage forms (emergency department, primary care, etc.) and the exact banding and actions vary between them; this screen uses the common Low / Moderate / High framing and deliberately errs toward escalation. Your facility sets the exact actions for each level. A negative screen never overrides clinical concern.

Disclaimer: Educational tool only — not a clinical decision-support device, not a diagnosis, and not a substitute for your assessment, your provider's evaluation, or your facility's suicide-risk policy. The C-SSRS Screen is a screen, not a full risk assessment; a positive screen should trigger a complete evaluation by a qualified clinician. Never leave a patient you are worried about alone, and follow your facility's suicide-precaution protocol. Enter de-identified values only; nothing is stored or transmitted. If you or someone you're with is in crisis, call or text 988 (988 Suicide & Crisis Lifeline, US) or your local emergency number.

References & attribution

Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266–1277. doi:10.1176/appi.ajp.2011.10111704.
Columbia–Suicide Severity Rating Scale, Screen Version – Recent. © 2008 The Research Foundation for Mental Hygiene, Inc. Question wording verified against the federally reproduced instrument. cms.gov (CMS-hosted form). For training and inquiries: Columbia Lighthouse Project.
The Columbia Lighthouse Project — the C-SSRS, risk triage (Low / Moderate / High) and recommended responses. cssrs.columbia.edu.

The C-SSRS is © 2008 The Research Foundation for Mental Hygiene, Inc., and is provided free of charge for use; questions are reproduced here for clinical screening with attribution. Your facility may use a locally adapted Columbia protocol and triage actions — those take precedence at the bedside.

Movement items (0–4)

0 None · 1 Minimal (may be extreme normal) · 2 Mild · 3 Moderate · 4 Severe. Observe the patient at rest and with activation maneuvers per the standard AIMS exam procedure.

1. Muscles of facial expression

2. Lips and perioral area

3. Jaw

4. Tongue

5. Upper extremities (arms, wrists, hands, fingers)

6. Lower extremities (legs, knees, ankles, toes)

7. Trunk (neck, shoulders, hips)

0/ 28 movement total · 0 of 7 items scored

Global judgments (0–4)

Recorded for documentation; not added to the 7-item movement total.

8. Overall severity of abnormal movements

9. Incapacitation due to abnormal movements

10. Patient’s awareness of abnormal movements (0 unaware → 4 aware + distress)

Dental status

Current problems with teeth and/or dentures

Does the patient usually wear dentures?

Rate the seven movement items to see the total and screen result.

Scoring & interpretation [1][2]

Each item is rated 0–4. The movement total sums items 1–7 (range 0–28). A commonly-used positive screen for possible tardive dyskinesia (the Schooler-Kane criteria) is a rating of moderate-or-worse (≥3) in at least one of the seven areas, or mild (≥2) in at least two areas. The AIMS is typically performed at baseline before/at antipsychotic start and repeated periodically (e.g., every 3–6 months, or per your protocol) to detect drug-induced movement disorders early. A positive or rising AIMS prompts provider evaluation and a medication review — it is not itself a diagnosis.

Disclaimer: Educational tool only — not a diagnosis and not a substitute for a trained examiner or provider judgment. Accurate AIMS scoring depends on the standardized examination procedure (observation at rest and with activation maneuvers). Movement findings can have many causes; interpretation and management are the provider’s. Enter de-identified values only; nothing is stored or transmitted.

References

Guy W. ECDEU Assessment Manual for Psychopharmacology, Revised. Rockville, MD: US Dept of Health, Education, and Welfare / NIMH; 1976:534–537. (Abnormal Involuntary Movement Scale — items, 0–4 anchors, and exam procedure; public domain.)
Schooler NR, Kane JM. Research diagnoses for tardive dyskinesia. Arch Gen Psychiatry. 1982;39(4):486–487. PMID: 6121548. (Positivity criteria: ≥2 in two areas or ≥3 in one.)

Items, anchors, and criteria transcribed from the AIMS (public domain) and the Schooler-Kane criteria. Clinical use is individualized by the care team.

Pairs well with

Psych Scored Assessments.

Over the last 2 weeks, how often bothered by…

References

Over the last 2 weeks, how often bothered by…

References

Columbia screener — Screen Version, Recent

How the screen triages [2][3]

References & attribution

Movement items (0–4)

Global judgments (0–4)

Dental status

Scoring & interpretation [1][2]

References

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