Anxiety & OCD Behavioral Health Center



1714500-57150000Self-Assessment ChecklistName: FORMTEXT ?????Date: FORMTEXT ?????AssessmentStructured Clinical Interviews / Clinician Administered InterviewsExperienceAnxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) – Adult and Lifetime Version Clinician ManualFamiliarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????Anxiety Disorders Interview Schedule for DSM-IV – Child Version (Parent and Child Interview Schedule)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????Structured Clinical Interview for DSM-5 (SCID-5)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????(Circle one or both) Yale-Brown Obsessive Compulsive Scale (YBOCS) OR Yale-Brown Obsessive Compulsive Scale-II (YBOCS-II)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????Other structured clinical interviews I have administered: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????Other structured clinical interviews I have administered: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Additional explanation: FORMTEXT ?????Self-Reported MeasuresExperience(Circle one or both) Anxiety Sensitivity Inventory -3 (ASI-3) OR previous versionsFamiliarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Beck Depression Inventory-II (BDI-II)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Structured Clinical Interview for DSM-5 (SCID-5) Screening Personality Questionnaire (SCID-5-SPQ)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????(Circle one or more) Adult ADHD Self-Report Scale Symptom Checklist (ASRS v1.1) OR Wender Utah Rating Scale OR Conners’ Adult ADHD Rating Scales OR Other Adult ADHD scales: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Alcohol Use Disorders Identification Test (AUDIT)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Drug Use Disorders Identification Test (DUDIT)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Panic Disorder Severity Scale (PDSS)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Mobility Inventory (MI)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Agoraphobic Cognitions Questionnaire (ACQ)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Penn State Worry Questionnaire (PSWQ)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Intolerance of Uncertainty Scale (IUS)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Obsessive Compulsive Inventory-Revised (OCI-R) OR other OCD screeners: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Obsessive Belief Questionnaire (OBQ)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Brief Fear of Negative Evaluation (BFNE)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????(Circle one or both) PTSD Checklist – 5 (PCLC-5) OR previous versionsFamiliarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????(Circle one or both) Massachusetts General Hospital Hairpulling Scale (MGH-HPS) or Other Hair pulling scales: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????(Circle one or both) Skin Picking Scale of Other Skin picking measures: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????NICHQ Vanderbilt Assessment ScalesFamiliarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Any child ADHD measure: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Eyberg Child Behavior Inventory (ECBI) OR any child behavioral disorder measure: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Screen for Child Anxiety Related Disorders (Parent/Child) OR other anxiety measure: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Childhood Anxiety Sensitivity Inventory (CASI)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Children’s Depression Inventory-2 (CDI-2) OR other depression measure: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Penn State Worry Questionnaire – Child Version (PSWQ-C)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Preschool Anxiety Scale (PAS)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Obsessive Compulsive Inventory-CV (OCI-CV) OR Children’s Florida Obsessive-Compulsive Inventory (C-FOCI) or other child OCD measure: FORMTEXT ?????Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????Obsessive Beliefs Questionnaire – Child Version (OBQ-CV)Familiarity: FORMCHECKBOX None FORMCHECKBOX Given a few (1-5) FORMCHECKBOX Given >5Scored: FORMCHECKBOX None FORMCHECKBOX Scored a few (1-5) FORMCHECKBOX Scored >5Additional explanation: FORMTEXT ?????ExperienceDisorderExperiencePanic Disorder/AgoraphobiaAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Generalized Anxiety DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Social Anxiety DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Separation Anxiety DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Selective MutismAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Specific PhobiaAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Disruptive Mood Dysregulation DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Major Depressive Disorder / Persistent Depressive DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Obsessive Compulsive DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Body Dysmorphic DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Hoarding DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????TrichotillomaniaAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Excoriation DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Posttraumatic Stress DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Acute Stress DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Adjustment DisordersAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Somatic Symptom DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Illness Anxiety DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Tourette’s Disorder / Persistent (Chronic) Motor or Vocal Tic Disorder / Provisional Tic DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Attention-Deficit/Hyperactivity DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Oppositional Defiant DisorderAdults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsTeens (>16) & Emerging Adults: FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsChildren & Teens (<16): FORMCHECKBOX None FORMCHECKBOX 1-5 patients FORMCHECKBOX >5 patientsManual/Protocol Read and Used: FORMTEXT ?????Ethics & SafetySkillsConfidence LevelAPA Ethical Principles of Psychologists and Code of ConductConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingIndiana State Psychology Board – Statutes and CodesConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingHealth Insurance Portability and Accountability Act (HIPAA)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSuicide Risk Assessment and Safety PlanningConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingViolence Risk Assessment and Safety PlanningConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSubpoenas and Court OrdersConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingTelepsychologyConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingPsychoeducation of Disorder/CBT Model/Functional AssessmentDisorderExperiencePanic Disorder/Agoraphobia (i.e., Fear of Fear; Physiology; Fight/Flight/Freeze; Myths)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingGeneralized Anxiety Disorder (i.e., Positive Beliefs about Worry, Behavioral Manifestations of Intolerance of Uncertainty)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSocial Anxiety Disorder (i.e., interpersonal model; ability to cope with rejection and criticism)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSeparation Anxiety DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSelective MutismConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSpecific PhobiaConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDisruptive Mood Dysregulation DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingMajor Depressive Disorder / Persistent Depressive DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (contamination and mental contamination)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (not just right experiences)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (scrupulosity)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (sexual obsessions)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (checking)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBody Dysmorphic DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingHoarding DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingTrichotillomania (e.g., SCAMP model)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingExcoriation Disorder (e.g., SCAMP model)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingPosttraumatic Stress Disorder Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingAcute Stress DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingAdjustment DisordersConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSomatic Symptom Disorder (e.g., IBS, fibromyalgia, chronic fatigue)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingIllness Anxiety DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingTourette’s Disorder / Persistent (Chronic) Motor or Vocal Tic Disorder / Provisional Tic Disorder (e.g., medication)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingAttention-Deficit/Hyperactivity Disorder (e.g., parenting principles, medication)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingOppositional Defiant Disorder (e.g., parenting principles)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSchool RefusalConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSpecific Treatment ComponentsSkillsConfidence LevelInteroceptive Exposure & Hierarchy Building & ImplementationConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingIn vivo Exposure & Hierarchy Building & ImplementationConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingImaginal Exposure & Hierarchy Building & ImplementationConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingThought RecordConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingCognitive RestructuringConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingMindfulnessConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBehavioral ActivationConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingAssertiveness Training/DBT: Interpersonal EffectivenessConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSocial Skills TrainingConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDBT: Emotional Regulation TrainingConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDBT: Distress Tolerance TrainingConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDBT: Walking the Middle PathConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDiscussing with Parents about Eliminating AccommodationsConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingAnger ManagementConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingMotivational Interviewing / Discussing Treatment Interfering Behaviors (TIBs)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBreathing / Relaxation / ImageryConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDiscussion of Diet/Exercise/SleepConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDiscussion of Alcohol and Drug UseConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingProblem SolvingConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingFunction-Based Intervention for TicsConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBFRB/Tic: Awareness TrainingConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBFRB/Tic: Stimulus ControlConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBFRB/Tic: Sensory SubstitutionConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBFRB/Tic: Competing ResponseConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingADHD/ODD: Daily Report CardsConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingADHD: Organizational SkillsConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingParenting: Praise/Incentives, Planned Ignoring, Effective Commands, Time Out, PunishmentConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingParenting: Problem Solve Negotiable Issues / Communicating with TeenagerConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingIncentive Plans for Motivating BehaviorConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingDiscussing MedicationConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingImplementation of ExposuresPanic Disorder/Agoraphobia (e.g., interoceptive exposure, In vivo, imaginal)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingGeneralized Anxiety Disorder (e.g., IU exposures, imaginal exposures)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSocial Anxiety Disorder (e.g., mistake practices, inconvenience practices)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSeparation Anxiety Disorder (e.g., in vivo exposures)A Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSelective Mutism (e.g., imaginal and in vivo exposures)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSpecific Phobia (e.g., flight, heights, dark, insects, vomit, blood/injury, driving, storms)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (contamination and mental contamination)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (not just right experiences)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (scrupulosity)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (sexual obsessions)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingObsessive Compulsive Disorder (checking, reread, rewrite, reassurance seeking, confess)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingBody Dysmorphic DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingHoarding Disorder (e.g., drive by shopping; discarding)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingTrichotillomaniaConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingExcoriation DisorderConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingPosttraumatic Stress Disorder (i.e., prolonged exposure)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSomatic Symptom Disorder Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingIllness Anxiety Disorder (e.g., use of blood pressure machine, needles)Confidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive TrainingSchool RefusalConfidence Level: FORMCHECKBOX Confident/Comfortable FORMCHECKBOX May Need Refresher FORMCHECKBOX Need Some Training FORMCHECKBOX Need Extensive Training ................
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