Assessment Form

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Operation Courage Assessment Form*

The questions in this evaluation ask you about your feelings and thoughts during the last two weeks to one month. In each case, you will be asked to indicate by selecting how often you felt or thought a certain way. There are two parts. *You must complete the evaluation in full to receive your results. The answers to this form are confidential, and will not be shared with employers or insurance companies in any way.

Part I: Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Select only one for each question)

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead, or of hurting yourself

Additional Questions

(Select only one)

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Continue to Part II

Part II: Generalized Anxiety Disorder Screener (GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Select only one for each question)

1. Feeling nervous, anxious or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble Relaxing

5. Being so restless that it is hard to sit still

6. Becoming easily annoyed or irritated

7. Feeling afraid as if something awful might happen

8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Additional Questions

(Select only one)

Q: When did the symptoms begin?

Continue to Results

Operation Courage Assessment Form
Evaluation Results

Thank you for submitting our evaluation form! Here are some general results, in addition to your results below:

- Feeling stressed by the COVID-19 pandemic? You are not alone.
- In crisis? Problems with alcohol or drugs? Thoughts of suicide?
Click here for immediate help: https://pressone.211md.org/

Part I: Patient Health Questionnaire (PHQ-9)

Score Legend

1-4 = Minimal Depression

5-9 = Mild Depression

10-14 = Moderate Depression

15-19 Moderately Severe Depression

20-27 Severe Depression

Part II: Generalize Anxiety Disorder Screener (GAD-7)

Score Legend

GAD-7 Score = 0-7
No Diagnosis

GAD-7 Score = 8+
Probably Anxiety Disorder

Submit Your Information

Want to discuss your results with a member of the Operation Courage team? Fill out your basic information below to submit your results to our team. We will be in touch to review with you!

Do you want to be contacted by us regarding your evaluation results?Yes, Please Contact Me

Enter Your First Name

Enter Your Last Name

Enter Your Phone Number

Enter Your Email Address

What is Your Profession?

What is the best day of the week to contact you?What is the best time of day to contact you?

Thank you for your submission, we will be in touch with you with the appropriate recommendations based on your scores!
We appreciate your interest and we look forward to working with you!

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Operation Courage Assessment Form*

Part I: Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Select only one for each question)

Additional Questions

(Select only one)

Part II: Generalized Anxiety Disorder Screener (GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Select only one for each question)

Additional Questions

(Select only one)

Operation Courage Assessment Form Evaluation Results

Part I: Patient Health Questionnaire (PHQ-9)

Score Legend

Part II: Generalize Anxiety Disorder Screener (GAD-7)

Score Legend

Submit Your Information

Do You Feel Like You Need Immediate Help?

Operation Courage Assessment Form
Evaluation Results