Step 1 of 5 20% Contact InformationName* First Name Last Name Gender*Please selectMaleFemaleNon-binaryDate Of Birth Date Format: MM slash DD slash YYYY Address*No. 01 Suite, No. 02 Building, No. 3 Jiangjun StreetDistrict*QingyangCity*ChengduProvince*SichuanCountry*Please selectChinaAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe About your furry companionName:*Species:*Please selectCanineFelineBreed (Retriever, mixed, etc.):*Estimated Weight (lbs):Gender*Please selectMaleFemaleAnimal Date Of Birth:* Date Format: MM slash DD slash YYYY Select A Pet Photo*Accepted file types: jpg, png, gif. Acceptable file formats: .gif, .jpg, .png. 1MB maximum file size. Min dimensions 400x300. Image will be resized. How do I resize my photo? AssessmentCopyright © 2013 American Psychiatric Association. All Rights Reserved. The questions below ask about things that might have bothered you. For each question, click the answer that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. SCORING: None - not at all Slight - rare, less than a day or two Mild - several days Moderate - more than half the days Severe - nearly every day * Domain: Depression1. Little interest or pleasure in doing things?*Select oneNoneSlightMildModerateSevere2. Feeling down, depressed, or hopeless?*Select oneNoneSlightMildModerateSevereDomain: Anger3. Feeling more irritated, grouchy, or angry than usual?*Select oneNoneSlightMildModerateSevereDomain: Mania4. Sleeping less than usual, but still have a lot of energy?*Select oneNoneSlightMildModerateSevere5. Starting lots more projects than usual or doing more risky things than usual?*Select oneNoneSlightMildModerateSevereDomain: Anxiety6. Feeling nervous, anxious, frightened, worried, or on edge?*Select oneNoneSlightMildModerateSevere7. Feeling panic or being frightened?*Select oneNoneSlightMildModerateSevere8. Avoiding situations that make you anxious?*Select oneNoneSlightMildModerateSevereDomain: Somatic Symptoms9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?*Select oneNoneSlightMildModerateSevere10. Feeling that your illnesses are not being taken seriously enough?*Select oneNoneSlightMildModerateSevereDomain: Psychosis11. Hearing things other people couldn’t hear, such as voices even when no one was around?*Select oneNoneSlightMildModerateSevere12. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?*Select oneNoneSlightMildModerateSevereDomain: Sleep Problems13. Problems with sleep that affected your sleep quality over all?*Select oneNoneSlightMildModerateSevereDomain: Memory14. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?*Select oneNoneSlightMildModerateSevereDomain: Repetitive Thoughts and Behaviors15. Unpleasant thoughts, urges, or images that repeatedly enter your mind?*Select oneNoneSlightMildModerateSevere16. Feeling driven to perform certain behaviors or mental acts over and over again?*Select oneNoneSlightMildModerateSevereDomain: Dissociation17. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?*Select oneNoneSlightMildModerateSevereDomain: Personality Functioning18. Not knowing who you really are or what you want out of life?*Select oneNoneSlightMildModerateSevere19. Not feeling close to other people or enjoying your relationships with them?*Select oneNoneSlightMildModerateSevere Suicidal Ideation22. Over the past two weeks, have you had thoughts of suicide?*Select oneNoYes23. Did your thoughts include a plan or intent to commit suicide?Select oneNoYes Notice of consentPlease note: submission of this form may take up to 30 seconds, as the form is being machine-evaluated.Consent Policy I agree to the consent policy. NESAA ID This iframe contains the logic required to handle Ajax powered Gravity Forms.