Clinical assessments & documentation

A complete reference for the assessment instruments Auxilison supports out of the box, organized by clinical domain. Program creators attach assessments to their programs at specific phase points; practitioners administer them as part of the program flow; outcomes aggregate to the creator's network view automatically.

Overview

Auxilison supports a comprehensive library of validated clinical assessment instruments, organized by clinical domain. Each assessment in the library includes the standard form, scoring logic, normative cut-points, and longitudinal trending visualizations. Program creators choose which instruments attach to their programs and at which phase points; practitioners administer them as part of the program flow; results aggregate automatically to the creator's network outcome view.

The library covers the assessments most commonly used in wellness program research and clinical practice across the nine verticals Auxilison serves — from general mental health screening to autonomic regulation measurement, from sleep assessment to trauma-specific instruments. The selection reflects what major research bodies (the VA, NIH-funded studies, IRB-approved clinical trials) actually use, with deliberate emphasis on instruments that are free, validated, and widely accepted in peer-reviewed work.

Creators can also author custom assessments specific to their methodology — see the final section.

Auxilison is not a diagnostic instrument and does not substitute for clinical judgment. Assessments delivered through the platform are screening, monitoring, and outcome-tracking tools used under the supervision of an appropriately credentialed practitioner.

How assessments work in Auxilison

Three roles interact with each assessment:

The creator selects and configures

In the Creator Studio (Programs › Program editor › Linked assessments), the creator chooses which instruments attach to each program and configures:

• When each assessment is administered — at baseline, at phase transitions, weekly, at completion, or on a custom schedule
• Who can see the results — practitioner only, practitioner and client, or full transparency
• Flagging rules — automatic alerts for elevated scores (e.g. PHQ-9 item 9 → C-SSRS escalation)
• Required vs. optional — whether the program continues if the assessment is skipped
• Scoring thresholds — using the published clinical cut-points or creator-defined thresholds for the program's population

The practitioner administers and reviews

In the Practitioner Workspace, assigned assessments appear in the client's profile timeline. The practitioner reviews completed results, sees longitudinal trends charted across the program arc, and is alerted when a score crosses a flagging threshold. The practitioner can also assign ad-hoc assessments outside the creator's standard schedule when clinical judgment indicates.

The client completes through the Client App

Assessments appear in the client's "More" tab under Assessments, or are surfaced in the program flow at the appropriate moment. Each assessment is rendered with the standard validated wording, response options, and instructions. The client completes; the result is saved and timestamped; the trend updates.

Outcomes aggregate to the network

In the Creator Studio's Outcomes view, assessment trajectories aggregate across the entire practitioner network. The creator can see average pre/post change, distribution of outcomes, cohort comparisons, and statistical confidence intervals where sample size supports them. This is the killer feature for evidence generation — assessment data from every client across every practitioner producing network-scale evidence for the methodology.

General mental health screening

The foundational instruments used across virtually every wellness vertical. Most programs include at least PHQ-9 and GAD-7 as baseline-and-outcome measures because depression and anxiety are common comorbidities of nearly every presenting concern.

PHQ-9 (Patient Health Questionnaire-9)

The PHQ-9 is the most widely used depression screening instrument in primary care and behavioral health worldwide. The VA uses it as a standard mental health screen. Its brevity, sensitivity to change, and free public-domain status make it the default depression measure for almost every program Auxilison serves.

PHQ-2

The PHQ-2 consists of the first two items of the PHQ-9 (depressed mood and anhedonia). Useful for high-volume triage settings or as a low-friction periodic check-in between full PHQ-9 administrations.

GAD-7 (Generalized Anxiety Disorder-7)

The GAD-7 is the standard anxiety measure for primary care and behavioral health. Like the PHQ-9, it is free, validated, sensitive to change, and accepted in virtually every research and clinical context. The two together form the "PHQ-9/GAD-7 pair" that anchors most mental health screening.

GAD-2

Brief version of the GAD-7, useful for triage or periodic check-ins.

K10 / K6 (Kessler Psychological Distress Scale)

The K10 measures non-specific psychological distress over the past 30 days. Frequently used in epidemiological research and population-health programs. Less common in individual-practitioner settings than the PHQ-9/GAD-7 pair, but appropriate for programs targeting broad well-being rather than specific symptom clusters.

DASS-21 (Depression Anxiety Stress Scales-21)

The DASS-21 is useful when a program wants to track stress as a separate construct from depression and anxiety. The stress subscale is the most distinctive — it captures tension, irritability, and tendency to overreact, which are particularly relevant for programs targeting nervous-system regulation or burnout.

BDI-II (Beck Depression Inventory-II)

The BDI-II is one of the most widely cited depression measures in the clinical literature. It is more comprehensive than the PHQ-9 but requires licensing. Programs that need BDI-II for research credibility or institutional requirements can use it; programs choosing freely will typically use the PHQ-9 instead.

BAI (Beck Anxiety Inventory)

The BAI is the BDI-II's companion anxiety measure. Same licensing considerations apply. Most programs use the GAD-7 instead unless BAI is specifically required.

Trauma and PTSD

The trauma assessment landscape is anchored by the PCL-5, the most widely used self-report PTSD measure in the world and the standard instrument in VA practice. Programs targeting trauma-affected populations should include PCL-5 as the headline outcome measure with C-SSRS for safety screening.

PCL-5 (PTSD Checklist for DSM-5) VA STANDARD

The PCL-5 is the VA's primary self-report PTSD measure. Any program targeting trauma-affected veterans should include PCL-5 as the primary outcome instrument. The 20 items map directly to the DSM-5 PTSD symptom criteria, organized into four clusters (intrusion, avoidance, negative alterations in cognitions and mood, alterations in arousal and reactivity).

PC-PTSD-5 (Primary Care PTSD Screen for DSM-5) VA STANDARD

The PC-PTSD-5 is the VA's standard PTSD screening instrument at primary care intake. A positive screen typically triggers full PCL-5 administration and clinical evaluation. Useful for programs that want to identify trauma history without putting every client through a 20-item assessment.

CAPS-5 (Clinician-Administered PTSD Scale)

The CAPS-5 is the gold-standard diagnostic interview for PTSD in research settings. It cannot be self-administered through a client app — it requires a trained clinician conducting a structured interview. Auxilison supports it as a practitioner-administered assessment where the practitioner enters responses during a session. Most programs use PCL-5 for screening and reserve CAPS-5 for confirmatory diagnostic work or research protocols requiring gold-standard measurement.

LEC-5 (Life Events Checklist for DSM-5)

The LEC-5 is not an outcome measure — it's a trauma history inventory. Used at baseline to establish what kinds of traumatic experiences the client has had. Particularly important for trauma-informed programs and for any work where the trauma context will inform clinical approach. Auxilison supports the standard LEC-5 plus an extended version that allows the creator to add program-specific items.

DTS (Davidson Trauma Scale)

The Davidson Trauma Scale is an alternative PTSD measure with strong validity but lower adoption than the PCL-5. Programs may use it for continuity with prior research or institutional preference.

IES-R (Impact of Event Scale-Revised)

The IES-R measures symptom intensity related to a specific identified traumatic event rather than general PTSD symptomatology. Useful for programs structured around processing a particular event or experience.

Sleep assessment

Sleep assessment is one of the most measurable wellness program targets. The PSQI is the most widely used research instrument; the ISI is more sensitive to change and better for trajectory tracking. Most sleep-focused programs include both.

PSQI (Pittsburgh Sleep Quality Index)

The PSQI is the most widely used clinical sleep assessment in the world. It is the standard sleep measure in VA research, NIH studies, and academic sleep medicine. Includes both subjective sleep quality and objective sleep parameters (estimated by self-report). Less sensitive to short-term change than the ISI — typically administered every 4-6 weeks rather than weekly.

ISI (Insomnia Severity Index)

The ISI is more sensitive to change than the PSQI and is the recommended instrument for tracking insomnia trajectory during a structured sleep program. Most VA sleep research uses ISI for weekly tracking with PSQI bookending baseline and completion.

ESS (Epworth Sleepiness Scale)

The ESS measures the functional impact of poor sleep — how much daytime sleepiness the person experiences. Useful as a secondary outcome alongside sleep-quality measures.

STOP-BANG

Not an outcome measure — a screening tool for obstructive sleep apnea. Important for sleep-focused programs because untreated sleep apnea is a major confound for any sleep intervention. Programs should screen and refer for evaluation when STOP-BANG indicates risk.

Sleep diary

The Consensus Sleep Diary is the standard research format. Daily sleep diaries are the most granular sleep data available and are heavily favored in VA sleep research for trajectory analysis. Auxilison supports the Consensus format plus customization for program-specific additions (medication tracking, intervention adherence, etc.). Diary data integrates into the longitudinal sleep visualization on the client profile and aggregates to the network outcome view.

DBAS-16 (Dysfunctional Beliefs and Attitudes about Sleep)

The DBAS-16 measures the cognitive contributors to insomnia (catastrophic thinking about sleep loss, worry about consequences, etc.). Relevant for programs with a cognitive-restructuring component. Useful as a process measure showing not just whether sleep improved but whether the underlying cognitive pattern shifted.

MEQ (Morningness-Eveningness Questionnaire)

The MEQ is not an outcome measure — it's a characterization measure used at baseline to understand the client's natural sleep-wake preference. Useful for sleep programs that recommend sleep-timing interventions, since intervention effectiveness varies by chronotype.

Autonomic regulation

For programs grounded in Polyvagal theory or other nervous-system frameworks (sound therapy, somatic work, breathwork, vibroacoustic interventions), the autonomic regulation measures are the mechanistic story. These instruments capture the construct the program claims to influence.

BBCSS (Body-Brain Center Suite of Scales)

The BBCSS is a suite of scales developed for use with autonomic-focused therapeutic work. Polyvagal-informed programs (including most sound-therapy programs in the Stephen Porges lineage) use the BBCSS as the headline mechanistic measure. Auxilison supports the full standard battery with optional inclusion of specific subscales based on program needs.

BPQ-20-ANS (Body Perception Questionnaire, 20-item ANS subscale)

The BPQ-20-ANS was developed by Stephen Porges as a compact measure of perceived autonomic reactivity. The 20-item subscale focuses specifically on the autonomic nervous system dimension. Strong fit for programs claiming autonomic regulation outcomes. Often paired with the BBCSS or used as an alternative.

HRV (Heart Rate Variability)

HRV is not a questionnaire — it's a physiological measure typically captured through wearable devices (Apple Watch, Oura, Garmin, Polar, dedicated HRV devices). Auxilison's wearable integration ingests HRV data from supported devices and presents it alongside self-report measures. For programs claiming autonomic regulation outcomes, paired HRV data substantially strengthens the evidence package. The integration is read-only and supplementary — HRV interpretation should always be paired with clinical judgment.

SUDS (Subjective Units of Distress Scale)

The SUDS is the simplest assessment in clinical use — a single number representing the client's current level of distress or activation. Despite (or because of) its simplicity, it is extremely useful for tracking moment-to-moment changes during a session, capturing immediate pre/post session shifts, and providing a low-friction continuous measure. Auxilison's pre/post session check-in flows commonly include a SUDS-style item.

Pain assessment

For programs targeting pain (functional medicine, vibroacoustic, somatic, certain integrative approaches), pain measurement is essential. The DVPRS is the VA's standard pain measure and the right choice for any veteran-facing work.

NRS (Numeric Rating Scale) / VAS (Visual Analog Scale)

The 0-10 pain scale is the most common pain measure in clinical practice. The NRS uses a numbered response; the VAS uses a visual line the client marks. Both are appropriate for periodic check-ins and pre/post session measurement.

BPI (Brief Pain Inventory)

The BPI captures both pain intensity and how much pain interferes with daily life (general activity, mood, walking, work, relationships, sleep, enjoyment). More informative than a single-number pain rating because interference often improves before raw pain intensity does — useful for measuring real functional gain.

DVPRS (Defense and Veterans Pain Rating Scale) VA STANDARD

The DVPRS is the VA/DoD standard pain measure. Developed specifically for military and veteran populations. The descriptive anchors (e.g. "interferes with concentration") make the 0-10 scale more reliable across raters. Any pain-related work intended for VA deployment should use the DVPRS as the primary pain measure.

McGill Pain Questionnaire

The McGill captures the qualitative dimensions of pain (throbbing, shooting, burning, etc.) beyond just intensity. Useful for research differentiating pain types or for programs targeting specific pain qualities. Less common in routine outcome measurement than the BPI or DVPRS due to length.

Tinnitus assessment

Tinnitus is the #1 service-connected VA disability. Sound-therapy and vibroacoustic programs sometimes target tinnitus management; for these programs, validated tinnitus measures are essential.

THI (Tinnitus Handicap Inventory)

The THI is the most widely used tinnitus impact measure. Captures the functional, emotional, and catastrophizing dimensions of tinnitus.

TFI (Tinnitus Functional Index)

The TFI is more sensitive to treatment-induced change than the THI and is the recommended primary outcome measure for tinnitus intervention research. Programs evaluating tinnitus treatment effectiveness should use the TFI.

THQ (Tinnitus Handicap Questionnaire)

Alternative tinnitus impact measure with strong validation. Less commonly used than THI or TFI but appropriate for continuity with prior research using this instrument.

Substance use & risk screening

Required for any program serving populations where substance use, suicide risk, or other safety concerns may be present. The VA requires C-SSRS as a standard suicide risk screen across virtually all behavioral health programs.

AUDIT / AUDIT-C VA STANDARD

The AUDIT-C is the VA's standard alcohol screening instrument. Any program serving veterans should include AUDIT-C at baseline. The full AUDIT provides more detailed information for clients who screen positive.

DAST-10 (Drug Abuse Screening Test-10)

The DAST-10 screens for drug use problems in the past 12 months. Useful for programs that may serve clients with substance use issues. Auxilison can be configured to require both AUDIT-C and DAST-10 at baseline for comprehensive substance use screening.

C-SSRS (Columbia-Suicide Severity Rating Scale) VA STANDARD

The C-SSRS is the VA standard for suicide risk screening and is required for most behavioral health work. Auxilison supports the standard C-SSRS with configurable flagging that automatically alerts the practitioner when elevated risk is indicated. Critically, the C-SSRS can be configured to trigger automatically when PHQ-9 item 9 (suicidal ideation) is elevated — closing the gap between depression screening and dedicated suicide risk assessment.

Programs serving any population with potential mental health vulnerability should include C-SSRS screening protocols.

Functional & quality of life

For programs claiming functional or quality-of-life improvements beyond symptom reduction, these instruments capture the broader life impact. The WHODAS 2.0 is the most widely used functional impact measure in international research.

WHODAS 2.0 (WHO Disability Assessment Schedule 2.0)

The WHODAS 2.0 is the standard functional impact measure in WHO research and is widely adopted in clinical outcome studies. The 12-item version is appropriate for routine outcome tracking; the 36-item version for deeper baseline characterization. Sensitive to change across a wide range of conditions.

SF-36 / SF-12 / SF-8 (Short Form Health Survey)

The SF-36 family is the most widely cited health-related quality-of-life measure in medical research. Used in thousands of studies across virtually every medical condition. Licensing complexity is the main barrier; programs choosing freely will often use WHOQOL-BREF instead.

WHOQOL-BREF

The WHOQOL-BREF is the free, WHO-developed quality-of-life measure that serves as the practical alternative to the SF-36 family. Validated across cultures and languages.

PROMIS measures

PROMIS (Patient-Reported Outcomes Measurement Information System) is the NIH-developed modular outcome measurement framework. It provides validated short forms and computer-adaptive tests across more than 70 health domains. Programs that want maximum measurement efficiency with full research validity often choose PROMIS short forms as their primary outcome measures.

Auxilison supports a curated set of PROMIS short forms commonly used in wellness program research: PROMIS Depression 8a, Anxiety 8a, Sleep Disturbance 8a, Pain Interference 8a, and Physical Function 10a. Additional PROMIS measures can be added on request.

Stress, resilience, well-being

For programs targeting stress reduction, resilience building, mindfulness cultivation, or general well-being, these positive-frame measures complement the symptom-focused instruments above.

PSS (Perceived Stress Scale)

The PSS is the most widely used measure of perceived stress in research. Captures the degree to which life situations are appraised as stressful. Useful as a primary or secondary outcome for stress-reduction programs.

CD-RISC (Connor-Davidson Resilience Scale)

The CD-RISC is the most widely used resilience measure. Useful for programs that frame outcomes in terms of resilience-building rather than symptom reduction.

WEMWBS (Warwick-Edinburgh Mental Wellbeing Scale)

The WEMWBS measures positive mental well-being rather than symptom presence. Particularly useful for wellness programs whose goal is flourishing rather than treatment of distress. The reduced 7-item SWEMWBS is increasingly preferred for its brevity and stronger psychometric properties.

FFMQ (Five Facet Mindfulness Questionnaire) / MAAS (Mindful Attention Awareness Scale)

The FFMQ captures five distinct facets of mindfulness, making it the more comprehensive instrument. The MAAS is briefer and focuses on present-moment attention. Programs with explicit mindfulness training components typically include one or both as process measures.

POMS (Profile of Mood States)

The POMS is widely used in psychophysiological and intervention research. The six mood subscales allow nuanced tracking of how interventions affect different mood dimensions. The licensing requirement limits adoption in self-funded programs.

Documentation formats

These are not assessment instruments — they are structured formats for practitioner notes. Auxilison's practitioner notes infrastructure supports these formats as templates, with AI session note generation able to produce drafts in any of these structures.

SOAP (Subjective, Objective, Assessment, Plan)

Structure

• S — Subjective: What the client reports (presenting complaints, symptoms, history as described, subjective experience)
• O — Objective: What the practitioner observes (mental status observations, behavioral observations, vital signs if applicable, assessment scores)
• A — Assessment: Clinical interpretation (diagnosis or formulation, clinical impression, progress assessment, risk evaluation)
• P — Plan: Next steps (treatment plan, interventions for next session, referrals, homework, follow-up schedule)

SOAP is the lingua franca of clinical documentation. Practitioners trained in medical or behavioral health settings will be familiar with it. Most appropriate for medical, functional medicine, and clinical mental health practitioners.

Auxilison's SOAP template includes structured fields for each section with optional sub-prompts (e.g. Subjective: "presenting concerns," "client-reported changes since last session," "homework completion"). The AI session note feature can generate SOAP-format drafts from session recordings.

DAP (Data, Assessment, Plan)

Structure

• D — Data: Combined subjective and objective information (what the client said, what the practitioner observed)
• A — Assessment: Clinical interpretation and progress evaluation
• P — Plan: Next steps and treatment plan

DAP collapses SOAP's Subjective and Objective sections into a single Data section, which many behavioral health practitioners find more natural since the boundary between subjective and objective in mental health work can be artificial. Common in counseling, coaching, and therapy contexts where the distinction matters less than in medical contexts.

BIRP (Behavior, Intervention, Response, Plan)

Structure

• B — Behavior: What the client presented with (behaviors, complaints, symptoms observed)
• I — Intervention: What the practitioner did (specific therapeutic interventions, techniques used, content of the session)
• R — Response: How the client responded (client engagement, response to interventions, in-session changes)
• P — Plan: Next steps

BIRP is particularly useful in mental health contexts where documenting specific interventions matters for clinical or billing reasons. The format makes it easy to track what was tried and how the client responded over time. Common in CBT, DBT, and intervention-specific therapeutic work.

GIRP (Goal, Intervention, Response, Plan)

Structure

• G — Goal: What the session focused on relative to the client's treatment goals
• I — Intervention: What the practitioner did
• R — Response: How the client responded
• P — Plan: Next steps

GIRP makes the connection between session work and overall treatment goals explicit. Useful for goal-oriented therapeutic work (solution-focused therapy, coaching, brief therapy) and for any context where documentation must demonstrate progress toward defined goals (insurance billing, outcomes-based contracts, structured programs with measurable objectives).

Custom assessments authored by the creator

Beyond the validated instruments in the standard library, creators can author custom assessments specific to their methodology. The custom assessment builder supports:

• Item types: Likert scales (3, 5, 7, 10 point), numeric input, free text, multiple choice (single and multi-select), date/time input, body diagrams, image-based response
• Scoring logic: Sum scores, averages, weighted scoring, subscale composition, conditional scoring rules
• Flagging thresholds: Creator-defined cut-points that trigger practitioner alerts
• Administration rules: Required vs. optional, frequency (one-time, periodic, event-triggered), phase-gated availability
• Visibility: Practitioner-only, practitioner-and-client, or fully transparent
• Localization: Multi-language support for items, instructions, and response options
• Versioning: Custom assessments are versioned alongside the program; changes propagate through version control

Custom assessments are particularly useful for programs whose methodology has specific constructs not well-captured by standardized instruments. Examples:

• A sound-therapy creator might author a "Listening Session Response Scale" capturing the specific qualities of subjective response they have refined through their training program
• A coaching creator might author goal-tracking assessments specific to the program's coaching framework
• A functional medicine creator might author symptom inventories aligned with the protocol's diagnostic categories
• An integration program creator might author preparation-readiness and integration-progress instruments specific to their preparation and integration arc

Custom assessments aggregate to the network outcome view just like standard instruments, allowing creators to generate evidence specific to their methodology's unique constructs.

The custom assessment builder does not provide automatic psychometric validation — the creator is responsible for the psychometric properties of any custom instrument they author. Auxilison provides the infrastructure to deploy and aggregate; clinical validity remains the creator's responsibility.

A note on selection and combination

The instruments above represent the standard library. Selecting which to include in a specific program depends on three considerations:

Program scope. Choose instruments that measure what the program actually claims to influence. A sleep program needs sleep measures. A trauma program needs trauma measures. A vibroacoustic program with mechanistic claims about autonomic regulation needs autonomic measures alongside the symptom-focused outcomes.

Required co-morbid screening. Most programs need at least basic mental health screening (PHQ-9, GAD-7) and risk screening (C-SSRS where appropriate). For VA-facing work, AUDIT-C is also typically required. Co-morbid screening is what distinguishes a serious clinical program from a casual wellness app.

Participant burden. Total assessment time should fit the program's structure. A 5-minute pre-session check-in is reasonable; a 90-minute assessment battery at baseline will suppress enrollment. Most programs land between 20-30 minutes at baseline, 5 minutes at weekly check-ins, and 20-30 minutes at completion. The Auxilison configuration tools surface the estimated participant time so the creator can manage burden deliberately.

For specific program design or VA pilot preparation, the Auxilison clinical advisory team can help select the optimal assessment battery for the program's evidence goals and population.