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Required format:

yGhFWDZeXkuuFfdezeKePIEFbBU9mLT4izWm

PQ-B

Please complete the survey below.

Thank you!

Date completed

Are you not sure if the RE-SET Program could be helpful to you or someone close to you? You can take this brief, anonymous survey to help determine if meeting with a member of our team for a more in-depth evaluation might be helpful for you or for the person on whose behalf you are completing it.

Your results to this survey are totally private and confidential.
This survey does not give you a diagnosis or a substitute for a professional mental health evaluation.

Do you reside in the state of Massachusetts?

Yes

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Thank you for your interest in taking this survey. Unfortunately, our program is only able to provide services to those residing in Massachusetts. We encourage you to locate a qualified mental health provider in your area to speak to about any questions or concerns you may be having.

Are you between the ages of 12-30 years?

Yes

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Thank you for your interest in taking this survey. Unfortunately, our program is only able to provide services to those between the ages of 12-30. We encourage you to look for another qualified mental health provider in your area to speak to about any questions or concerns you may be having.

1. Do familiar surroundings sometimes seem strange, confusing, threatening or unreal to you?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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2. Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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3. Do things that you see appear different from the way they usually do (brighter or duller, larger or smaller, or changed in some other way)?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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4. Have you had experiences with telepathy, psychic forces, or fortune telling?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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5. Have you felt that you are not in control of your own ideas or thoughts?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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6. Do you have difficulty getting your point across, because you ramble or go off the track a lot when you talk?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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7. Do you have strong feelings or beliefs about being unusually gifted or talented in some way?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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8. Do you feel that other people are watching you or talking about you?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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9. Do you sometimes get strange feelings on or just beneath your skin, like bugs crawling?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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10. Do you sometimes feel suddenly distracted by distant sounds that you are not normally aware of?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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11. Have you had the sense that some person or force is around you, although you couldnմ see anyone?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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12. Do you worry at times that something may be wrong with your mind?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

13. Have you ever felt that you don't exist, the world does not exist, or that you are dead?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

14. Have you been confused at times whether something you experienced was real or imaginary?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

15. Do you hold beliefs that other people would find unusual or bizarre?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

16. Do you feel that parts of your body have changed in some way, or that parts of your body are working differently?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

17. Are your thoughts sometimes so strong that you can almost hear them?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

18. Do you find yourself feeling mistrustful or suspicious of other people?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

19. Have you seen unusual things like flashes, flames, blinding light, or geometric figures?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

20. Have you seen things that other people can't see or don't seem to see?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

21. Do people sometimes find it hard to understand what you are saying?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

* must provide value

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

reset

Total items

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Thank you for taking this survey. Your answers suggest that you could greatly benefit from a more in-depth evaluation with a member of our team. It's always a good idea to talk to a qualified professional about your mental health concerns. You can feel better with the right kind of help.

You can complete a referral to our program here: https://redcap.link/7mlw4ixp as a next step. We will then review it to see if you are eligible for an evaluation. Please call us at (617) 643-1204 with any questions.

Thank you for taking this survey. Your answers suggest that you could benefit from a more in-depth evaluation with a member of our team. It's always a good idea to talk to a qualified professional about your mental health concerns. You can feel better with the right kind of help.

You can complete a referral to our program here: https://redcap.link/7mlw4ixp as a next step. We will then review it to see if you are eligible for an evaluation. Please call us at (617) 643-1204 with any questions.

Thank you for taking this survey. Your answers suggest that you may be having some concerns with your mental health and may benefit from a more in-depth evaluation. It's always a good idea to talk to a qualified professional about your mental health concerns.

If you think we may be able to help, you can complete a referral to our program here: https://redcap.link/7mlw4ixp. We will then review it to see if you are eligible for an evaluation. Please call us at (617) 643-1204 with any questions.

Thank you for taking this survey. Your answers suggest that you may be having some mental health experiences that could be worthwhile to speak about with a qualified mental health professional. If experiences asked about in this survey worsen or start to bother you more, please consider completing a referral here: https://redcap.link/7mlw4ixp to see if you are eligible for an evaluation with our program. Please call us at (617) 643-1204 with any questions.

Thank you for taking this survey. Based on the answers you provided, you are not currently having mental health experiences where completing an evaluation through our program is recommended at this time. However, if you are concerned about your mental health, you can always seek out a qualified mental health professional who may be a better fit to help with experiences you are having.

If you have any questions about our program, please call us at (617) 643-1204.

If you think you may hurt yourself, someone else, or attempt suicide, get help right away by taking one of these actions:
• Call 911 or your local mental health crisis service
• Go to the nearest emergency room
• Seek help from your doctor or other health care provider
• Call the 24/7 National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained crisis counselor
• Text HOME to 741741 to connect with a crisis counselor 24/7 https://www.crisistextline.org/

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.