Makin Wellness Clinical Tools

Perinatal

Perinatal Screeners

Depression, anxiety, birth trauma, safety and psychosis-risk screening across pregnancy and the first postpartum year.

EPDS — Edinburgh Postnatal Depression Scale, 10 items, with item 10 handled as a self-harm item rather than a checkbox
Abuse Assessment Screen — IPV, asked only when she is alone
PASS — Perinatal Anxiety Screening Scale, 31 items; catches the anxiety the EPDS was never built to find
City BiTS — City Birth Trauma Scale, 29 items; birth-related PTSD scored against the DSM-5 algorithm rather than a cut-off, with birth-related and general symptoms read separately
PRIME Screen–Revised 5 — psychosis-risk triage

Clinical Assessment

ADHD · Anxiety · Trauma · Risk · Child · Firearm · Autism · Resilience

Seventeen instruments in one place. Pick the domain along the top, then the instrument.

ADHD — BAARS-IV Current Symptoms (27), Childhood Symptoms (18) and Quick Screen, age-normed for adults 18–89
ADHD, retrospective — WURS-25, childhood symptoms rated by the adult, with both published cut-offs
Anxiety — HAM-A, 14 clinician-rated items with the psychic and somatic split
Trauma — PCL-5 with LEC-5 and Criterion A; total against the cut-off and the DSM-5 cluster rule
Childhood adversity — ACE, ten categories; a population measure with no clinical cut point, carried with the cautions its own authors published
Dissociation — DES-II, 28 items scored as a mean, with the amnesia, depersonalisation and absorption subscales and the DES-Taxon
Suicide risk — C-SSRS with triage points, and SAFE-T, which reads the C-SSRS answers rather than asking twice
Child anxiety — SCARED, child and parent versions, ages 8–18; total plus five subscale cut-offs, and the two forms read against each other
Firearm evaluation — PF-10, a ten-domain structured professional judgment framework for firearm ownership suitability; forensic, and deliberately produces no score
Autism — AQ (50 items, self-report screen) and RAADS-R (80 items, given with a clinician present); both carry the referred-population caveats on screen
Repetitive behavior — RBQ-2A, adult self-report; a dimensional severity measure with no cut-off, for describing a pattern rather than screening for one
Resilience — Brief Resilience Scale, six items measuring recovery from stress; descriptive norms, no clinical cut-off, and best read as change across a course of treatment

Every instrument, at a glance

Twenty-two instruments across two tools. Each link opens straight to that instrument.

Instrument	What it is for	Items	Tool
EPDS	Perinatal depression, with item 10 handled as a self-harm item	10	Perinatal
Abuse Assessment Screen	Intimate partner violence — asked only when she is alone	5	Perinatal
PASS	Perinatal anxiety — cut-off 26, four symptom domains, item 7 read alone as a phobia indicator	31	Perinatal
City BiTS	Birth-related PTSD — DSM-5 algorithm rather than a cut-off, with birth-related and general subscales	29	Perinatal
PRIME Screen–Revised 5	Psychosis-risk triage for a younger client with unusual thought content	5	Perinatal
BAARS-IV Current Symptoms	Adult ADHD now, past six months, with SCT scored separately	27	Assessment
BAARS-IV Childhood Symptoms	Recalled ages 5–12, for the DSM-5 onset criterion	18	Assessment
BAARS-IV Quick Screen	ADHD triage — inattention items only, so run the full form for hyperactive presentations	9	Assessment
WURS-25	Childhood ADHD recalled by the adult — cut-offs at 30 and 46, three subscales	25	Assessment
HAM-A	Anxiety severity and tracking — clinician-rated, not self-report	14	Assessment
PCL-5 with LEC-5	PTSD symptoms against one index event, with Criterion A and cluster scoring	20	Assessment
DES-II	Dissociative experiences — a mean, not a total, with the DES-Taxon for pathological dissociation	28	Assessment
ACE	Ten categories of childhood adversity — a count, not a severity score, and not diagnostic for an individual	10	Assessment
C-SSRS Screen	Suicide risk screening with Columbia’s triage points	6	Assessment
SAFE-T	Full five-step suicide assessment and documentation — reads the C-SSRS answers	5 steps	Assessment
SCARED — Child	Child anxiety, ages 8–18, self-reported — total plus five subscale cut-offs	41	Assessment
SCARED — Parent	The same 41 items answered by a parent about the child — meant to be read against the child form	41	Assessment
PF-10	Firearm ownership suitability — ten-domain SPJ framework, forensic, no score by design	10 domains	Assessment
AQ	Adult autism screen — two thresholds, both shown; a low score does not rule autism out in someone referred	50	Assessment
RAADS-R	Structured autism symptom review, given with a clinician present — not a screen for a referred population	80	Assessment
RBQ-2A	Restricted and repetitive behavior in adults — a severity mean, no cut-off, not a screen for autism	20	Assessment
BRS	Recovery from stress — a mean with descriptive norms, no clinical cut-off, and no perinatal validation	6	Assessment

Which one do I need?

By what the client brings, not by diagnosis.

Pregnant or within a year of birth — any presentation	EPDS, every time
Low mood, tearfulness, or “I don’t feel like myself” postpartum	EPDS
Anxious, on edge, or worrying constantly — perinatal	PASS, alongside the EPDS
A difficult, frightening or traumatic birth — at any point in the first year	City BiTS, alongside the EPDS
She keeps returning to the birth, avoids the hospital, or cannot talk about the delivery	City BiTS — watch the birth-related subscale
Unusual thought content in a younger client	PRIME-5
“I think I have ADHD” — adult	Quick Screen, then the full form
Establishing childhood onset for an adult ADHD question	BAARS-IV Childhood Symptoms
Corroborating that childhood picture a second way	WURS-25
Worry, tension, restlessness — severity and tracking	HAM-A
Trauma history, or symptoms tied to a specific event	PCL-5 with LEC-5
Childhood adversity history, as a way into the conversation	ACE — read the cautions first
Feeling unreal, losing time, gaps in memory	DES-II
Trauma work stalling, or planning EMDR preparation	DES-II, before exposure work
Any mention of not wanting to be here	C-SSRS, in session, today
C-SSRS is positive — full risk assessment and documentation	SAFE-T
An anxious child or teenager, ages 8–18	SCARED, child and parent versions
A child refusing school, or with stomachaches and headaches on school mornings	SCARED — watch the school avoidance and somatic subscales
A parent says the child is fine and the child says otherwise	SCARED — run both, the gap is the finding
Firearm ownership suitability, or restoration of gun rights	PF-10 — forensic, no score
“I think I might be autistic” — adult, first conversation	AQ — read the caveats before you read the score
Structured symptom review in an adult already under autism assessment	RAADS-R, with you in the room
Describing repetitive behavior in an adult already under autism assessment	RBQ-2A — severity, not screening
Tracking whether someone is recovering from stress across a course of treatment	BRS — repeat it, read the change
Looking for protective factors or coping resources	Not the BRS — it measures bounce-back only

The same four rules apply to all of them

A score is not a diagnosis. Every instrument here narrows the question. None of them answers it, and none of them replaces the interview.

Paste the note into the Optional Screening Tools section. Each tool writes a chart-ready note and marks where it goes. Print or save as PDF gives you the whole note, not the on-screen box.

No client data lives here. Nothing is stored by these pages, and completed screeners belong in the record — not in Drive, not in email.

Consult before you are certain. Your clinical supervisor is the first call when a screen is positive, when risk is present, or when the picture does not add up. 988 call or text · county crisis line for the county the client is sitting in (county crisis, not 988, authorizes a 302) · 911 / ED for immediate danger.

Built for the internal clinical use of Makin Wellness. Each tool carries the full citation and licence for the instruments it contains.