Form GAIN-MSS

       Form Approved

OMB NO. 0930-0276

Exp. Date: xx-xx-xxxx

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0276. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Global Assessment of Individual Needs-Modified Short Screener

D ATE (Today’s Date) /

Month Day Year

CHILD ID Number :  - - 

GAIN is a copy righted instrument and cannot be copied for local purposes. If you would like to purchase this instrument please contact:

www.chestnut.org/LI/gain/

OR

Joan Unsicker

Chestnut Health Systems, 448 Wylie Drive,

Normal, IL 61761

Phone: 309-451-7700

Fax: 309-451-7761

[email protected]

GAIN – Modified Short Screener

This section should be completed by youth aged 12 and older.

When was the last time, if ever, you used…

1-2 days

3-7 days

1-4 weeks

1-3 months

4-12 months

1+ years

Never

1. any kind of alcohol (beer, gin, rum, scotch, tequila, whiskey, wine or mixed drinks?

2. alcohol until you were drunk (or had 5 or more drinks)?

3. marijuana, hashish, blunts or other forms of THC (herb, reefer, weed)?

4. cocaine, opiods, methamphetamine, or any other drug including a prescription medication that was not prescribed to you, or one that you took more than you were supposed to?

5. During the past 90 days, on how many days have you…

1. used any kind of alcohol (beer, gin, rum, scotch, tequila, whiskey, wine or mixed drinks? |__|__| Days

2. gotten drunk or had 5 or more drinks? |__|__| Days

3. used marijuana, hashish, blunts or THC (herb, reefer, weed)? |__|__| Days

4. used cocaine, opioids, methamphetamine or any other drug, including a prescription medication that was not prescribed to you, or one that you took more of than you were supposed to? |__|__| Days

When was the last time…	Past Month	2-12 Months Ago	1+ Years Ago	Never
6. you used alcohol or other drugs weekly or more often?
7. 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?
8. 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?
9. 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?
10. 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?