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  • Mentalhealth Intake

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    kaitlyn meyers
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    Please complete this form prior to your initial intake and present it to you provider at your appointment.

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    © © All Rights Reserved

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    Please complete this form prior to your initial intake and present it to you provider at your appointment.

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF o leggi online su Scribd
    Segnala contenuti inappropriati
    31 visualizzazioni3 pagine

    Mentalhealth Intake

    Caricato da

    kaitlyn meyers
    Please complete this form prior to your initial intake and present it to you provider at your appointment.

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF o leggi online su Scribd
    Segnala contenuti inappropriati
    di 3
    eee) it) QUESTIONNAIRE-9 (PHQ-9) Over te as 2 wets, tow on have you bon kthereg ace byany oft folsesree a sevens git Mey _(Use “eto incite your answer) days thedays day ‘Lite ines or peasie in ing ge Bleep cece eta 2 Feoing down, depressed or opaos ae 3 Trouble faling or staying asleep, or sleeping too much ° 1 Fi 3 4. Feeling tired or having fit energy 0 1 2 s 5. Poor appetite or overeating ° 1 2 3 © Feeling bad about yoursstf — or that you area fare or have let yourself or your family dow 7, Trouble concentrating on things, such as reading the ‘pewspaper or watching television 5 Moving or speaking so slowiy tat oihor people could have nalleed? Or the opposite — being so fidgety or voters ° 1 2 3 ret you nave been moving around a lot more than eco 2° Toasahts that you would be beter of dad or of hurting Yourself in some way Fororrice copie _o You checked off any problems, how afficul have tesa Broblems mad it for you to do your ork te care of things at home, or got along with other bos ey Not difficutt Somewhat Vary Extremely atall difficult difficatt difficult o a o o Pear: Roca atan Spar Janet BW. Wilms, Ku Kroenke and colesgue, wih an eductane! sant rom Pfzer ine. No permission required 10 reproduce, tansate, depioy er sean Generalized Anxiety Disorder 7-item (GAD-7) scale Over the last 2 weeks, how often have you been Nott Sever) Overhalf Nearly bothered by the following problems? allsure days the days every day |. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying o 1 2 3 3. Worrying too much about different things 0 ! 2 3 4, Trouble relaxing ° I 2 3 5. Being so restless that it's hard to sit still 0 1 2 6. Becoming easily annoyed or irritable 0 : 2 7 7. Feeling afraid as if s mmething awful might 0 1 2 3 happen Add the score for each column + + + Total Score (add your cohunn scores) = L If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Source: Spitzer RL. Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety Aisorder. Arch Inern Med. 2006166; 1092-1097, Mental Health Intake Form Please complete all information on this form and bring it to the first visit It ‘may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you! Name_ Date, Primary Care Physician eee eeeeanag gece Do you give permission for ongoing regular updates to be provided to your primary care physician? Date of Birth Current Therapist/Counsclor___ Therapist's Phone __ ‘What are the problem(s) for which you are seeking help? i 2, 3 What are your treatment goals? Current Symptoms Cheehlist: (check once for any symptoms present, twice for major symptoms) ( ) Depressed mood ( ) Racing thoughts ( ) Bxeessive worry (_) Unable to enjoy activities (_ )Impulsivity ( )Amxiety attacks (_ ) Sleep pattern disturbance ( ) Increase risky behavior ( ) Avoidance ( ) Loss of interest (_ ) Increased libido ( ) Hallucinations (_ ) Concentration/forgetfulness (_) Decrease need for sleep ( )Suspiciousness ( ) Change in appetite (_ ) Excessive energy ©). ( ) Excessive guilt ( )Imereased irritability ) ( ) Fatigue C ) Crying spells ( ) Decreased libido Suicide Risk Assessment Trvgyou ever had feelings or thoughts that you didn't want to live? ( ) Yes ( )No. IEYES, please answer the following. If NO, please skip to the next section, Do you eurrently feel that you don't want to live? ( ) Yes ( ) No How often do you have these thoughts? ‘When was the last time you had thoughts of dying? Has anything happened recently to make you feel this way? Ona scale of | to 10, (ten being strongest) how strong is your desire to Kill yourself currently? Would anything make it better? Have you ever thought about how you would kill yoursell Is the method you would use ‘readily available? Have you planned a time for this? = 5 ain Is there anything that would stop you from killing yourself Do you feel hopeless and/or worthless? -

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