Intake Screening Forms

Name: *

Parent/Guardian Name (if patient is under 18):

Date: * +

Section 1: Risk Factors

Substance Abuse: *

Yes

No

Firearms in the household: *

Yes

No

Previous suicide attempt *

Yes

No

Non-suicidal self-injury *

Yes

No

Exposure to friends'/family members' suicide *

Yes

No

Low self-esteem/self-hate/shame *

Yes

No

Hopelessness *

Yes

No

Family history of suicide *

Yes

No

Recent discharge from an inpatient psychiatric or substance abuse facility *

Yes

No

Recent losses (career, people, housing, relationships, pets, etc.) *

Yes

No

Current suicidal ideation (intent, plan, access to means, preparation) *

Yes

No

History of trauma or abuse (physical, sexual, and/or emotional) *

Yes

No

Co-morbid health problems/physical pain *

Yes

No

Sexual Orientation/identity *

Yes

No

Financial stress *

Yes

No

Access to medication *

Yes

No

History of psychosis (hallucinations) *

Yes

No

Fire-setting, animal cruelty and/or bed-wetting *

Yes

No

Served in Military/Veteran *

Yes

No

Psychological pain (hurt, anguish, misery) *

Yes

No

Legal matters/career or school problems *

Yes

No

Bullying (victim or perpetrator) *

Yes

No

Impulsivity/poor self-control (gambling, promiscuity, spending, shoplifting, etc.) *

Yes

No

Section 2: Protective Factors

Positive social supports *

Yes

No

Spirituality/religious connection *

Yes

No

Life satisfaction *

Yes

No

Children in the home, pregnancy *

Yes

No

Sense of responsibility of to family, friends, and/or pets *

Yes

No

Positive coping/problem-solving skills *

Yes

No

Job/school satisfaction *

Yes

No

Future oriented *

Yes

No

Any weapons I may have are safely secure *

Yes

No

Positive therapeutic relationship *

Yes

No

I acknowledge this Risk Assessment is completed to the best of my ability.

Signature: *

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Parent/Guardian Signature (if under 18):

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PAIN, HEALTH & NUTRITION SCREENING

Name: *

Date: * +

Section 1: Health & Medical Status

A. Physical Exam

Have you had a physical exam within the last 12 months? *

Yes

No

N/A

B. Are you currently experiencing any of the following health problems?

1. Diabetes *

Yes

No

N/A

2. Heart problems *

Yes

No

N/A

3. High blood pressure *

Yes

No

N/A

4. Seizures *

Yes

No

N/A

5. Hearing problems *

Yes

No

N/A

6. Vision problems *

Yes

No

N/A

7. Speech problems *

Yes

No

N/A

8. Muscle or joint problems *

Yes

No

N/A

9. Nausea or vomiting *

Yes

No

N/A

10. Other medical conditions *

Yes

No

N/A

C. Primary Care Physician

If you are experiencing any of the health problems listed above, are you being treated by a primary care provider for identified problem(s)? *

Yes

No

N/A

Section 2: Pain

A. Are you experiencing any ongoing physical pain? *

Yes

No

N/A

B. How would you rate the intensity of the pain on a scale from 1 to 10, with 10 being the worst possible pain you could imagine? : *

C. Are you currently being treated for this pain? *

Yes

No

N/A

D. If "yes", is the treatment effective? * *

Yes

No

N/A

Section 3: Nutrition

A. Have you experienced an unintentional weight loss or gain of 10 pounds or more within the last month? *

Yes

No

N/A

B. Has a doctor or other medical professional placed you on a special diet? *

Yes

No

N/A

C. Do you have behaviors that are chronic and interfere with feeding yourself? *

Yes

No

N/A

If "yes" to question c, please select which behaviors:

a. chewing *

Yes

No

N/A

b. swallowing *

Yes

No

N/A

c. gastric difficulties *

Yes

No

N/A

e. bulimia *

Yes

No

N/A

d. anorexia *

Yes

No

N/A

f. binge eating *

Yes

No

N/A

I acknowledge this Pain, Health and Nutrition Screening is completed to the best of my ability.

Signature: *

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Parent/Guardian Signature (if under 18):

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Intake DASS-21

Please read each statement and select a number of 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are not right or wrong answers. Do not spend too much time on any one statement. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak to a qualified health professional.

(0) Did not apply to me at all
(1) Applied to me to some degree or for some of the time
(2) Applied to me a considerable degree of for a good part of the time
(3) Applied to me very much or most of the time

1) I found it hard to wind down *

2) I was aware of dryness of my mouth *

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

4) I experienced breathing difficulty (ex. excessively rapid breathing, breathlessness in the absence of physical exertion) *

5) I found it difficult to work up the imitative to do things *

6) I tended to over-react to situations *

7) I experienced trembling (ex. in the hands) *

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

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

10) I felt that I had nothing to look forward to *

11) I felt myself getting agitated *

12) I found it difficult to relax *

13) I felt down-hearted and blue *

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

15) I felt I was close to panic *

16) I was unable to become enthusiastic about anything *

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

18) I felt that I was rather touchy *

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

20) I felt scared without any good reason *

21) I felt that life was meaningless *

DASS 21 Severity Ratings

Severity Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 16-33

Extremeny Severe 28+ 20+ 34+

Please press the calculate buttons to continue.

Depression Total:

0

Anxiety Total:

0

Stress Total:

0

PHQ-9 (Patient Health Questionnaire-9)

How often have they been bothered by the following over the past 2 weeks?

Little interest or pleasure in doing things? *

Feeling down, depressed, or hopeless? *

Trouble falling or staying asleep, or sleeping too much? *

Poor appetite or overeating? *

Feeling tired or having little energy? *

Thoughts that you would be better off dead, or thoughts of hurting yourself in some way? *

Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual? *

Trouble concentrating on things, such as reading the newspaper or watching television? *

Feeling bad about yourself — or that you are a failure or have let yourself or your family down? *

Please press the calculate button to continue.

Points:

0

Mood Disorder Questionnaire (MDQ)

Instructions: Check mark the answer that best applies to you. Please answer each question as best you can.

1. Has there ever been a period of time when you were not your usual self and…

you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? *

Yes

No

you were so irritable that you shouted at people or started fights or arguments? *

Yes

No

you felt much more self-confident than usual? *

Yes

No

you got much less sleep than usual and found you didn’t really miss it? *

Yes

No

you were much more talkative or spoke faster than usual? *

Yes

No

thoughts raced through your head or you couldn’t slow your mind down? *

Yes

No

you were so easily distracted by things around you that you had trouble concentrating or staying on track? *

Yes

No

you had much more energy than usual? *

Yes

No

you were much more active or did many more things than usual? *

Yes

No

you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? *

Yes

No

you were much more interested in sex than usual? *

Yes

No

you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? *

Yes

No

spending money got you or your family in trouble? *

Yes

No

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Please check 1 response only. *

Yes

No

3. How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights? Please check 1 response only. *

4. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *

Yes

No

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *

Yes

No

Hamilton Anxiety Rating Scale (HAM-A)

Below is a list of phrases that describe certain feeling that people have. Rate the patients by finding the answer which best describes the extent to which he/she has these conditions. Select one of the five responses for each of the fourteen questions.

1. Anxious Mood: Worries, anticipation of the worst, fearful anticipation, irritability *

2 Tension: Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax. *

3 Fears: Of dark, of strangers, of being left alone, of animals, of traffic, of crowds. *

4 Insomnia: Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors. *

5 Intellectual: Difficulty in concentration, poor memory *

6 Depressed mood: Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing. *

7 Somatic (muscular): Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone. *

8 Somatic (sensory): Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation. *

9 Cardiovascular symptoms: Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat *

10 Respiratory symptoms: Pressure or constriction in chest, choking feelings, sighing, dyspnea *

11 Gastrointestinal symptoms: Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation. *

12 Genitourinary symptoms: Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence. *

13 Autonomic symptoms: Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair. *

14 Behavior at interview: Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc. *

Please press calculate button to continue.

Total:

0

Name: *

Signature: *

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Parent/Guardian Signature (if patient is under 18):

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