Are you a provider or are you self-referring?
* must provide value
I am a provider referring a patient
I am referring myself
Welcome to the Grady Trauma Project's online provider referral system! Please complete the following information to ensure that we process this referral as quickly as possible. After being referred, potential GTP participants will be contacted to determine eligibility for our treatment opportunities and/or studies. Please confirm that the individual you are referring is:
* must provide value
What is the name of the person you are referring?
* must provide value
(First Name, Last Name)
What is their date of birth?
(Please note GTP can only enroll individuals 18-65 years of age)
Today M-D-Y If this is unknown please leave blank.
What is their race or ethnicity?
Woman Man Non-Binary Gender Fluid Other
What is the best phone number to reach them?
*Please note, this phone number should be a direct way to reach the patient. We cannot contact family members or other individuals.*
Are you referring this individual to a SPECIFIC GTP Study?
Are you referring this individual to a specific GTP Study or Program?
* must provide value
From where are you referring this individual?
Primary Care Clinics Outpatient Psych (Park Place) OB/GYN Clinic Diabetes Emergency Department Orthopedics Nia Project Trauma Recovery Center Other
From where are you referring this individual?
Is this individual currently in an inpatient facility for treatment?
Yes
No
If inpatient, please describe when they will most likely be out for us to reach them.
(First Name, Last Name)
What is your best contact phone number?
What is your best contact email?
If you are referring to a specific study, please choose the study here:
E2 Goal-Directed Resilience in Training (GRIT) Mindfulness in Primary Care (MPC) Physiological Augmentation of Mindfulness Meditation (PAMM) Pregnancy Study Amygdala DBT Pregnancy Study Other
Is there anything else you'd like for us to know? (e.g., active symptoms, scores on PHQ-9 or PC-PTSD, if the participant is pregnant)?
FOR GTP STAFF: What was the outcome of follow-up?
MPC PAMM GRIT E2 Avon Pregnancy Critical Periods DBT Pregnancy Referred to walk-in group Not eligible Unable to reach
Welcome to the Grady Trauma Project's self-referral system! Please complete the following information to ensure that we process this referral as quickly as possible. After being referred, you will be contacted to determine eligibility for our treatment opportunities and/or studies. Please check the box indicating your age range:
* must provide value
18 or older
Less than 18 - please call the GA Crisis Line (1-800-715-4225) for referral to appropriate services
In what state do you live?
* must provide value
Georgia
Outside of Georgia - please call the GA Crisis Line (1-800-715-4225) for referral to appropriate services
(First Name, Last Name)
What is the best phone number to reach you?
What is the best email to reach you?
What is your date of birth?
* must provide value
Today M-D-Y If this is unknown please leave blank.
Woman Man Non-Binary Gender Fluid Other
Are you currently pregnant, breastfeeding, or taking hormonal contraception?
Pregnant
Breastfeeding
Hormonal Contraceptives
None of the Above
Today M-D-Y
How did you hear about the Grady Trauma Project?
Saw a Flyer about Grady Trauma Project
Saw a Flyer about Goal Directed Resilience Training
Saw a Flyer about the hormones and stress study
Referred by a friend
Other
Given this website by a GTP caller
Saw a Flyer about the Yoga (EMBODY) study
How did you hear about us?
What is your race or ethnicity?
* must provide value
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide.
Have you ever experienced this kind of event?
* must provide value
Yes No
Have you ever served (or do you currently serve) in the U.S. military or the military reserves?
* must provide value
Yes No
Approximately how many times have you experienced a traumatic event?
* must provide value
Please answer the following questions about problems you might be experiencing as a result of your traumatic experiences. In the PAST MONTH, have you ...
Had nightmares about the event(s) or thought about the event(s) when you did not want to?
* must provide value
Yes No
Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
* must provide value
Yes No
Been constantly on guard, watchful, or easily startled?
* must provide value
Yes No
Felt numb or detached from people, activities, or your surroundings?
* must provide value
Yes No
Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
* must provide value
Yes No
View equation Little interest or pleasure in doing things
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep, or sleeping too much
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Feeling tired or having little energy
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Poor appetite or overeating
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Feeling bad about yourself - or that you're a failure or have let yourself or your family down
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Trouble concentrating on things such as reading or watching television
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Moving or speaking so slowly that people notice. Or the opposite - being so fidgity or restless that you have been moving around a lot more than usual
* must provide value
Not at all
A few days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
* must provide value
Not at all
A few days
More than half the days
Nearly every day
View equation If you are currently in crisis and are in need of support, please call the GA Crisis Line at 1-800-715-4225 or 911, or you can immediately go to the closest emergency room.
* must provide value
I am not in crisis and wish to continue with the survey
During the last month, on average, how often do you have a drink containing alcohol?
* must provide value
Never
Monthly
2-4 times a month
2-3 times a week
4 or more times a week
In the past month, have you had 4 or more alcohol drinks within 2-3 hours?
* must provide value
Yes No
In the past month, have you had 5 or more alcohol drinks within 2-3 hours?
* must provide value
Yes No
During the last month, on average, how many drinks containing alcohol do you have on a typical drinking day?
* must provide value
0 to 2
3 to 4
5 to 6
7 to 9
10 or more
During the last month, how often do you have six or more drinks on one occasion?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last month have you found that you were unable to stop drinking once you started?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last month have you failed to do what was normally expected of you because of drinking?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last month have you needed a first drink in the morning to get yourself going after heavy drinking?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last month have you felt guilt or remorse after drinking?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last month have you been unable to remember what happened the night before because of drinking?
* must provide value
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Have you or someone else been injured as the result of your drinking?
* must provide value
No
Yes, but not in the last year
Yes, during the last year
Has a friend, relative, doctor or other health worker been concerned about your drinking or suggested you cut down?
* must provide value
No
Yes, but not in the last year
Yes, during the last year
View equation In the last month, have you used drugs other than those required for medical reasons?
* must provide value
No
Yes
In the last month, have you abused more than one drug at a time?
* must provide value
No
Yes
In the last month, were you always able to stop using drugs when you wanted to?
* must provide value
No
Yes
In the last month, have you had "blackouts" or "flashbacks" as a result of drug use?
* must provide value
No
Yes
In the last month, have you felt bad or guilty about your drug use?
* must provide value
No
Yes
In the last month, has your spouse (or parents) complained about your involvement w/drugs?
* must provide value
No
Yes
In the last month, have you neglected your family because of your drug use?
* must provide value
No
Yes
In the last month, have you engaged in illegal activities in order to obtain drugs?
* must provide value
No
Yes
In the last month, have you had withdrawal symptoms when you stopped talking drugs?
* must provide value
No
Yes
In the last month, have you had medical problems as a result of your drug use?
* must provide value
No
Yes
View equation Do you currently use any form of nicotine? (Cigarettes, e-cigarettes, Hookahs, patches, gum, vapes)
* must provide value
No
Yes
Do you take any medication for your mood?
* must provide value
No
Yes
What mood medication do you take?
Are you claustrophopic (are you afraid of going into an elevator?)
Yes
No
Do you have any metal in your body? (DOES NOT include removable piercings, fillings, copper IUD)
Yes
No
During the past week, how often did you think you had special powers?
* must provide value
Never
Rarely
Sometimes
Often
Always
During the past week, how often did you hear voices or see things that others couldn't see?
* must provide value
Never
Rarely
Sometimes
Often
Always
During the past week, how often did you think people were spying on you?
* must provide value
Never
Rarely
Sometimes
Often
Always
During the past week, how often did you think people were plotting against you?
* must provide value
Never
Rarely
Sometimes
Often
Always
View equation
Thank you for completing this survey! Please click "submit" below. FOR GTP STAFF: Was this participant scheduled for a screen?
Yes
No
FOR GTP STAFF: What was the outcome of follow-up?
MPC MIND GRIT E2 Avon Pregnancy Critical Periods (NO LONGER RECRUITING) DBT Pregnancy Referred to walk-in group (NOT ACTIVE) Not eligible Unable to reach
Submit
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