Preview – Stage 1 Intake v2 – The Optimal Mind

Skip to content

Search

About
Blog
Contact
Blueprint
Prescreener

Search

Search

About
Blog
Contact
Blueprint
Prescreener

Search

Step 1 of 8

12%

Welcome to the Pre-Screening Assessment

This assessment helps us understand your current psychological profile to ensure we can provide the most appropriate support. Please answer all questions honestly - there are no right or wrong answers.

Estimated time: 10-15 minutes

Your Goals

What are you hoping to achieve through coaching? What specific changes would you like to see in your life?(Required)

Personal Growth Initiative

Please indicate how much you agree or disagree with each statement as it applies to you right now.

1) I set realistic goals for what I want to change about myself.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

2) I can tell when I am ready to make specific changes in myself.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

3) I know when I need to make a specific change in myself.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

4) When I try to change myself, I make a realistic plan for how to change.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

5) I have a plan for making my life more balanced.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

6) I know what I need to do to get started toward reaching my goals.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

7) I have a specific action plan to help me reach my goals.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

8) I look for opportunities to grow as a person.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

9) When I want to make a change in myself, I seek out help and support from others.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

10) I actively seek out resources (like books, internet, or other people) when I want to grow.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

11) I know when I need to seek help to grow as a person.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

12) I take charge of my life.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

13) I know steps I can take to make intentional changes in myself.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

14) If I want to change something in my life, I initiate the transition process.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

15) I can choose the role that I want to have in a group.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

16) I actively work to improve myself.(Required)

Disagree Strongly

Disagree Somewhat

Disagree A Little

Agree A Little

Agree Somewhat

Agree Strongly

How You've Been Feeling

Please read each statement and indicate how much the statement applied to you over the past week.

1) I found it hard to wind down(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

2) I was aware of dryness of my mouth(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

3) I couldn't seem to experience any positive feeling at all(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

4) I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion)(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

5) I found it difficult to work up the initiative to do things(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

6) I tended to over-react to situations(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

7) I experienced trembling (e.g., in the hands)(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

8) I felt that I was using a lot of nervous energy(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

9) I was worried about situations in which I might panic and make a fool of myself(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

10) I felt that I had nothing to look forward to(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

11) I found myself getting agitated(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

12) I found it difficult to relax(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

13) I felt down-hearted and blue(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

14) I was intolerant of anything that kept me from getting on with what I was doing(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

15) I felt I was close to panic(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

16) I was unable to become enthusiastic about anything(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

17) I felt I wasn't worth much as a person(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

18) I felt that I was rather touchy(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

19) I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat)(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

20) I felt scared without any good reason(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

21) I felt that life was meaningless(Required)

Did not apply to me at all

Applied to me to some degree, or some of the time

Applied to me to a considerable degree, or a good part of the time

Applied to me very much, or most of the time

Focus, Planning & Follow Through

Please answer the questions below, rating yourself on each of the criteria shown. As you answer each question, select the response that best describes how you have felt and conducted yourself over the past 6 months.

1) How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?(Required)

Never

Rarely

Sometimes

Often

Very Often

2) How often do you have difficulty getting things in order when you have to do a task that requires organization?(Required)

Never

Rarely

Sometimes

Often

Very Often

3) How often do you have problems remembering appointments or obligations?(Required)

Never

Rarely

Sometimes

Often

Very Often

4) When you have a task that requires a lot of thought, how often do you avoid or delay getting started?(Required)

Never

Rarely

Sometimes

Often

Very Often

5) How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?(Required)

Never

Rarely

Sometimes

Often

Very Often

6) How often do you feel overly active and compelled to do things, like you were driven by a motor?(Required)

Never

Rarely

Sometimes

Often

Very Often

Interpersonal Style

Please indicate how much you agree or disagree with each statement.

1) It's not wise to tell your secrets.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

2) I like to use clever manipulation to get my way.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

3) Whatever it takes, you must get the important people on your side.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

4) Avoid direct conflict with others because they may be useful in the future.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5) It's wise to keep track of information that you can use against people later.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

6) You should wait for the right time to get back at people.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

7) There are things you should hide from other people to preserve your reputation.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

8) Make sure your plans benefit yourself, not others.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

9) Most people can be manipulated.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

10) People who mess with me always regret it.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

11) I'll say anything to get what I want.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

12) I like to get revenge on authorities.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

13) I avoid dangerous situations.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

14) Payback needs to be quick and nasty.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

15) People often say I'm out of control.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

16) It's true that I can be mean to others.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

17) I have never gotten into trouble with the law.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

18) I enjoy having sex with people I hardly know.(Required)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Self-Perception

For each pair of statements, please select the one that comes closest to describing your feelings and beliefs about yourself. You may feel that neither statement describes you well, but pick the one that comes closest.

1) Select the statement that best describes you:(Required)

I prefer to blend in with the crowd

I like to be the center of attention

2) Select the statement that best describes you:(Required)

I insist upon getting the respect that is due me

I usually get the respect that I deserve

3) Select the statement that best describes you:(Required)

I am no better or no worse than most people

I think I am a special person

4) Select the statement that best describes you:(Required)

I don't mind following orders

I like having authority over people

5) Select the statement that best describes you:(Required)

I don't like it when I find myself manipulating people

I find it easy to manipulate people

6) Select the statement that best describes you:(Required)

I don't particularly like to show off my body

I like to show off my body

7) Select the statement that best describes you:(Required)

I try not to be a show off

I will usually show off if I get the chance

8) Select the statement that best describes you:(Required)

I always know what I am doing

Sometimes I am not sure of what I am doing

9) Select the statement that best describes you:(Required)

I expect a great deal from other people

I like to do things for other people

10) Select the statement that best describes you:(Required)

Being an authority doesn't mean that much to me

People always seem to recognize my authority

11) Select the statement that best describes you:(Required)

I am going to be a great person

I hope I am going to be successful

12) Select the statement that best describes you:(Required)

I am a born leader

Leadership is a quality that takes a long time to develop

13) Select the statement that best describes you:(Required)

I wish somebody would someday write my biography

I don't like people to pry into my life for any reason

Behavioral Reflection

Please answer the following questions thoughtfully. These help us understand how you handle important interpersonal situations.

Can you describe a time when you made a significant mistake that affected others? How did you handle it?(Required)

When you have hurt or disappointed someone important to you, how do you typically try to make things right?(Required)

How do you usually respond when someone sets a boundary with you that you disagree with?(Required)

Thank You

You have completed the pre-screening assessment. Please click Submit below to send your responses.

This field is hidden when viewing the form

PGIS Total

This field is hidden when viewing the form

PGIS Mean

This field is hidden when viewing the form

PGIS Green

This field is hidden when viewing the form

PGIS Amber

This field is hidden when viewing the form

PGIS Red

This field is hidden when viewing the form

DASS Depression Raw

This field is hidden when viewing the form

DASS Depression Score

This field is hidden when viewing the form

DASS Anxiety Raw

This field is hidden when viewing the form

DASS Anxiety Score

This field is hidden when viewing the form

DASS Stress Raw

This field is hidden when viewing the form

DASS Stress Score

This field is hidden when viewing the form

DASS Depression Red

This field is hidden when viewing the form

DASS Depression Amber

This field is hidden when viewing the form

DASS Anxiety Red

This field is hidden when viewing the form

DASS Anxiety Amber

This field is hidden when viewing the form

DASS Stress Red

This field is hidden when viewing the form

DASS Stress Amber

This field is hidden when viewing the form

ASRS Flag Count

This field is hidden when viewing the form

ASRS Positive

This field is hidden when viewing the form

SD3 Mach Total

This field is hidden when viewing the form

SD3 Mach Mean

This field is hidden when viewing the form

SD3 Mach Amber

This field is hidden when viewing the form

SD3 Mach Red

This field is hidden when viewing the form

SD3 Psych Total

This field is hidden when viewing the form

SD3 Psych Mean

This field is hidden when viewing the form

SD3 Psych Amber

This field is hidden when viewing the form

SD3 Psych Red

This field is hidden when viewing the form

NPI Total

This field is hidden when viewing the form

NPI E/E Total

This field is hidden when viewing the form

NPI E/E Green

This field is hidden when viewing the form

NPI E/E Amber

This field is hidden when viewing the form

NPI E/E Red

This field is hidden when viewing the form

Clinical Review Flag

This field is hidden when viewing the form

Engagement Risk Flag

This field is hidden when viewing the form

Decline Risk Flag

This field is hidden when viewing the form

Total Red Flags

This field is hidden when viewing the form

Total Amber Flags

© 2026 The Optimal Mind. All Rights Reserved.

About
Blog
Contact
Blueprint
Prescreener

About
Blog
Contact
Blueprint
Prescreener

Scroll to Top