EVIDENCE-BASED SCREENING TOOLS:

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• Alcohol: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

  • https://www.merckmanuals.com/professional/multimedia/clinical-calculator/ciwa-ar-clinical-institute-withdrawal-assessment-for-alcohol-scale​

• Attention Deficit Hyperactivity Disorder (ADHD)

  • https://www.nichq.org/sites/default/files/resource-file/NICHQ-Vanderbilt-Assessment-Scales.pdf​

• Clinical Opiate Withdrawal Scale (COW)

  • https://nida.nih.gov/sites/default/files/ClinicalOpiateWithdrawalScale.pdf​

• Cognition

  • MOCA (Montreal Cognitive Assessment): https://www.mocatest.org/​

  • Mini Mental Status Exam: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/cogimp-smmse.pdf

• Depression

  • PHQ-9: https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf​

• Generalized Anxiety Disorder (GAD)

  • GAD-7: https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf​

• Suicidality

  • Columbia-Suicide Severity Rating Scale (C-SSRS): https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf​