EASA Services Questionnaire

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The following questions will ask about thoughts, feelings, or experiences. When answering, consider only experiences you've had in the past 30 days when you were fully awake and not under the influence of any substances.

The same questions are asked of everyone, and there are no right or wrong answers. Unless you consent provide your contact information and request that someone get in touch with you, your responses will remain anonymous.

pqb date

Are you a resident of Oregon between the ages of 15 and 29?

Yes

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In the past 30 days, when you were fully awake and not under the influence of any substances:

Do familiar surroundings sometimes seem strange, confusing, threatening, or unreal to you?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears?

* must provide value

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do things that you see appear different from the way they usually do (brighter or duller, larger or smaller, or changed in some other way)?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you had experiences with telepathy, psychic forces, or fortune telling?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you felt that you are not in control of your own ideas or thoughts?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you have difficulty getting your point across because you ramble or go off the track a lot when you talk?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you have strong feelings or beliefs about being unusually gifted or talented in some way?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you feel that other people are watching you or talking about you?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you sometimes get strange feelings on or just beneath your skin, like bugs crawling?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you sometimes feel suddenly distracted by distant sounds that you are not normally aware of?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you had the sense that some person or force is around you, although you couldn't see anyone?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you worry at times that something may be wrong with your mind?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you ever felt that you don't exist, the world does not exist, or that you are dead?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you been confused at times whether something you experienced was real or imaginary?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you hold beliefs that other people would find unusual or bizarre?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you feel that parts of your body have changed in some way, or that parts of your body are working differently?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Are your thoughts sometimes so strong that you can almost hear them?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do you find yourself feeling mistrustful or suspicious of other people?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you seen unusual things like flashes, flames, blinding light, or geometric figures (not associated with a migraine or right before a bad headache)?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Have you seen things that other people can't see or don't seem to see?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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Do people sometimes find it hard to understand what you are saying?

Yes

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When this happens, I feel frightened, concerned, or it causes problems for me:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

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PQ-B Distress Score

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PQ-B Symptoms score

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Your score indicates you are not experiencing significant symptoms of psychosis at this time.
If you are in crisis or experiencing other distressing mental health symptoms, please call your local crisis line, 911, 988, or go to the nearest emergency room.
National crisis line: 1-800-273-8255, or text HOME to 741741.

Your score, Symptom Score: ______, Distress Score: ______, suggests that it may be helpful for you to talk with a professional who works for the EASA program.
Would you be interested in having someone from the EASA program reach out to you with more information?

* must provide value

Yes

I'm not sure. Tell me more about EASA before I decide.

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What is EASA? The Early Assessment and Support Alliance (EASA) is a network of community mental health agencies devoted to providing early assessment, support, and services to young people experiencing symptoms of psychosis. Our services are provided free or low-cost to participants, and can include peer support, family support, medical support, 1:1 counseling, help with jobs and school, and more. These services are provided through a number of different agencies across the state of Oregon. If you'd like more detail, please visit our website: EASA Services

Now that you have had an opportunity to learn more about us, would you be interested in having someone from the EASA program reach out to you with more information?

Yes

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You have indicated that you do not wish to be contacted by a professional at EASA at this time. If you would like to learn more about the EASA program in your area, please visit our website: http://www.easacommunity.org/easa-programs.php
If you are in crisis or experiencing or experiencing distress, please call your local crisis line, 911, 988, or go to the nearest emergency room.
You can access the national crisis line by calling 1-800-273-8255, or by texting HOME to 741741.

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