Wilmington DE and Newark DE Psychiatrists Specializing in Cognitive Behavioral Therapy, Electroconvulsive therapy, Transcranial Magnetic Stimulation, Eye movement desensitization and reprocessing, Play Therapy, Post-traumatic Stress Disorder, and Depression

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Generalized Anxiety Disorder-7 (GAD-7)

GAD-7

This form screens for and quantifies the severity of anxiety.

First Name (first 3 letters only)*
Last Name (first 3 letters only)*
Date of birth*
MM slash DD slash YYYY
Phone number (last 4 digits only)*

Enter last 4 digits of phone number in file with us. If you do not have a phone number enter 0000.
Provider's name (choose one)*
- Sandeep K. Gupta, MD
- Parth M. Viroja, MD
- Michal Tomaszewicz, PMHNP
- Julia A. Jordan, PMHNP
- Janet M. Brown, PMHCNS
- Michelle F. Lauer, PMHNP
- Susan Epps, PhD
Choose one from above by clicking inside the circle
Generalized Anxiety Disorder (GAD-7) (screens for and quantifies the severity of anxiety)
How often have you been bothered by the following over the last 2 weeks? Select one answer choice for each of the questions below.
1. Feeling nervous, anxious, or on edge*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
2. Not being able to stop or control worrying*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
3. Worrying too much about different things*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
4. Trouble relaxing*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
5. Being so restless that it's hard to sit still*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
6. Becoming easily annoyed or irritable*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
7. Feeling afraid as if something awful might happen*
- Not at all [0]
- Several days [+1]
- More than half the days [+2]
- Nearly every day [+3]
If you checked off any of the above, how difficult have these problems made it to do work, take care of things at home, or get along with other people?*
- Not at all
- Somewhat difficult
- Very difficult
- Extremely difficult
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You can also schedule directly by calling (302)478-6199 during normal business hours. If this is an emergency, please call 911.

Name*
First Last
Age*
Please enter a number from 1 to 125.
Email*
Phone*
Type of service requested (choose all that apply)*
- Medication managment
- Talk Therapy
- Transcranial Magnetic Stimulation
Note: TMS refers to Transcranial Magnetic Stimulation
Requested appointment location (choose all that apply)*
- Select All
- Wilmington (Foulk Road)
- Newark (Omega Drive)
- Telehealth (Remote)
Note: Initial TMS consult is offered in both Wilmington and Newark but actual treatment is offered in Newark office only.
Name of insurance company*
What are your concerns?*
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Email
This field is for validation purposes and should be left unchanged.