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Sample Questionnaires

Following are examples of ACORN questionnaires currently in use by various organizations.

All questionnaires can be completed online or using paper and pencil. Papers forms are faxed to a secure toll free number for data entry. All questionnaires based on ACORN items are offered free of charge. Charges apply for use of the ACORN Toolkit for online completion and data entry services for faxed forms.

To view summary outcome data for different questionnaires, diagnoses and payer plan type, see ACORN Toolkit Summary Results Viewer

Adobe Acrobat Reader Version 7.0 or later recommended.

Adult questionnaires

Click on the questionnaire name to download a sample form.

  • Adult-Ver10
    • This is one example of a brief outcome questionnaire intended for a general outpatient mental health population. It provides a brief, reliable and valid measure of global distress/well-being.
    • Global Distress Scale reliability (coefficient alpha) = .9 based on sample of 215,281 administrations.
    • Items correlated strongly with global factor and items from similar adult questionnaires such as the PHQ9, GAD7, OQ45 & SCL90
    • Other adult questionnaires show other possible variations of form layout and item content.
  • Adult Ver11
    • Similar to Version 10, but with consumer friendly layout. Fields completed by office are moved to bottom of the form and labeled as such.
    • Global Distress Scale reliability (coefficient alpha) = .9 based on sample of 215,281 administrations.
    • Layout of form designed by patient completing ACORN questionnaires.
    • This layout has been adopted across multiple questionnaires.
  • Adult-SPMI
    • This questionnaire was developed for use with patients with severe and persistent mental illness who are receiving long term care in intensive outpatient or residential treatment programs.
    • Global Distress Scale reliability (coefficient alpha) = .89 based on sample of 32,722 administrations.
  • Adult Recovery Questionnaire
    • This questionnaire combines items from the global distress domain with items designed for use in 12-step based recovery programs which assess the client's progress towards recovery.
    • Global Distress Scale reliability (coefficient alpha) = .91 based on sample of 40,277 administrations.
  • Gambling Questionnaire
    • This questionnaire combines items from the global distress domain with items designed for use in gambling addictions recovery programs which assess the client's progress towards recovery.
    • Global Distress Scale reliability (coefficient alpha) = .9 based on sample of 2279 administrations.
  • Adult-Eating Disorder Questionnaire: Adult-Ver4-EatingDisorder.pdf
    • This questionnaires is intended for use with an eating disorder population. Field trials confirm that the eating disorder specific items correlated highly with the global distress factor.
    • Global Distress Scale reliability (coefficient alpha) = .94 based on sample of 1159 administrations.
  • Adult-Ver11 Prescriber: Adult-Ver11-Prescriber.pdf
    • This questionnaire is used by prescribers providing medication management services for adults. The questionnaire includes items of specific interest to prescribers.
    • Global Distress Scale reliability (coefficient alpha) = .88 based on sample of 1849 administrations.
  • Adult Trauma Questionnaire: Adult-Ver11-Trauma.pdf
    • This questionnaire contains items indicative of PTSD symptoms in trauma survivors. When used with a treatment population on survivors, these trauma items correlated highly with the global distress scale.
    • Global Distress Scale reliability (coefficient alpha) = .88 based on sample of 1814 administrations.
  • Outcome & Religious Coping
    • This questionnaire incorporates items from the Brief Religious Coping Questionnaire. Change on these items has been shown to correlate with overall improvement among clients with strong religious beliefs.
    • Global Distress Scale reliability (coefficient alpha) = .9 based on sample of 1247 administrations.
  • PHQ9-GAD
    • This questionnaire combined items from the PHQ9 and GAD7 to create a questionnaire with better psychometric properties as an outcome questionnaire than either alone.
    • Includes alliance items
    • Reliability estimated to be .9 based on a sample of >77,000 administrations.
    • Factor analysis reveals the same common factor as other ACORN questionnaires.
    • Concurrent validity study with ACORN adult questionnaire reveals high correlations over repeated assessment during the course of treatment.
    • Both ACORN and PHQ9-GAD derived questionnaires showed similar rates of improvement and high correlations between change scores on each measure.
    • For more information, including factor analysis, see Kaiser Permanente PHQ9 validity study

Youth and child measures

  • Adolescent Outcome Questionnaires-Ver. 11
    • Combines youth or caregiver versions into a single form. Identity of respondent is identified by check box at top of form.
    • This form designed based on feedback from multiple clinicians in the field.
    • Global Distress Scale reliability (coefficient alpha) = .9 based on sample of 52,041 administrations.
  • Adolescent Outcome Questionnaires-Ver. 12
    • This version contains items reflecting strengths and self esteem. Factor analysis confirms that these positive items correlate strongly with the same common factor as items reflecting distress.
    • Global Distress Scale reliability (coefficient alpha) = .83 based on sample of 763 administrations.
  • Adolescent Outcome Questionnaire - Behavioral
    • This questionnaire focuses on behavioral issues. It combines items from the Peabody Battery with items to rate the working alliance.
    • Factor analyses of this and related ACORN child & youth measures reveal all items correlated with a common factor.
    • Use of varimax factor rotation reveals weak factors reflecting externalizing and internalizing symptoms.
    • Externalizing and internalizing items both correlate with common factor, and can be scored as a single Global Distress scale.
    • Global Distress Scale reliability (coefficient alpha) = .88 based on sample of 18,036 administrations.
  • Child Outcome Questionnaire-Ver11
    • This is a subsequent iteration of a child measure, combining child and caretaker versions into a single form with a check box to indicate respondent.
    • Form layout based on feedback from consumer completing questionnaires in treatment.
    • Global Distress Scale reliability (coefficient alpha) = .88 based on sample of 102,469 administrations.
  • Child Outcome Questionnaire - Behavioral
    • This questionnaire measure is intended for children age 5 to 11. This range can be extended based on clinician judgement.
    • It combines items from the Peabody Battery with items to rate the working alliance.
    • Global Distress Scale reliability (coefficient alpha) = .91 based on sample of 24,955 administrations.
  • Youth-Ver11 Prescriber
    • This questionnaire is used by prescribers providing medication management services for youth. The questionnaire includes items of specific interest to prescribers.
    • Global Distress Scale reliability (coefficient alpha) = .87 based on sample of 457 administrations.

Meta questionnaires

Meta questionnaires survey clients or clinicians believes and attitudes regarding the use of other questionnaires.

  • Meta-Questionnaire Feedback Form
    • This questionnaire asks the client to give feedback on the ACORN questionnaires
    • Client perception of the forms is highly dependent on whether they perceive that the therapist is interested in their responses on the outcome questionnaires.
    • If the client perceives that that therapist was interested, 95% found the questionnaires helpful, fewer than 15% had concerns about the questionnaires, and 95% reported that the responded honestly.

ACORN Manual Table of Contents

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