FORMS

Complete Screening Form Before Scheduling Appointment

Client Forms

  1. Screening Form (New Client)
  2. Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7)

1. Screening Form (New Client)

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Are you in crisis? (Refer to ER if YES, if NO make appointment)(required)
Are currently on Psychiatric Medications?(required)
Are you stable on your medications?(required)
Are you currently seeing a psychiatrist?(required)
Are you currently seeing a therapist?(required)
Any outpatient or inpatient treatment for mental health or substance abuse?(required)
Any history of suicide attempt?(required)
Do you feel that you are harm to yourself or others?(required)
Any suicidal and/or homicidal plans or intent?(required)
Do you experience any symptoms of depression, anxiety and panic attacks?(required)

2. Patient Health Questionnaire and General Anxiety Disorder(PHQ-9 and GAD-7)

PHQ-9 and GAD-7 Form_QuestiionnaireDownload

Write PHQ-9 and GAD-7 Questionnaire Answers below:

PHQ-9 Total Score (add your column scores): _____________

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?

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GAD-7 Total Score (add your column scores): _____________

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?

Check mark one