Client Information Client Information Client Name* First Last Birthdate* MM slash DD slash YYYY Age*Are you (the client) 18 years of age or older?* Yes No What are the problems you are experiencing?*When did the problem(s) start ?* Tell us about your family and the people who live with you.*What has been done in the past to try and solve the problem(s)?* Individual Therapy Family Therapy Group Therapy Medication Therapy Substance Abuse Treatment Self Help Groups Partial Hospitalization Psychiatric Hospitalization Therapeutic Foster Care Other None of the above What is the date you were released from the hospital? MM slash DD slash YYYY Who could help or support you in making changes in your life?* Mother Father Step-parent Spouse or partner Foster parent Grandparent Aunt and Uncle or other family member Children Friend(s) I do not have any supportive people in my life. I do not need support. Other Have you experienced any of the following risks to safety?* Suicidal thoughts or feelings Made plans to hurt yourself Attempted suicide in the past Cut or intentionally injured yourself Thoughts or feelings of harming someone else. Previous aggressive acts toward others Episodes of alcohol intoxication Episodes of impulsive behavior Set things on fire Psychosis or delusions Sexual offending behavior Coping with significant loss such as a job or relationship. Partner violence Dislike of one’s own body or gender None of the above Have you ever been diagnosed with or suspected you have ADD or ADHD ( Attention Defiicit Hyperactive Disorder)* Yes No In the past 7 days have you experienced any of the following? 1. I failed to give close attention to details or made careless mistakes in schoolwork, work, or other activites.0-Not at all.1-Just a little2-Quite a bit3-Very much2. I often have difficulty sustaining my attention in tasks or play activities.0-Not at all.1-Just a little2-Quite a bit3-Very much3. I often do not seem to be listening when spoken to directly.0-Not at all.1-Just a little2-Quite a bit3-Very much4. I often do not follow through on instructions and fail to finish schoolwork, chores, or duties.0-Not at all.1-Just a little2-Quite a bit3-Very much5. I often have difficulty organizing tasks and activities.0-Not at all.1-Just a little2-Quite a bit3-Very much6. I often avoid, dislike or an reluctant to engage in tasks that require sustained mental effort such as school or homework.0-Not at all.1-Just a little2-Quite a bit3-Very much7. I often lose things necessary for tasks or activities such as toys, school assignments, pencils, books, or tools.0-Not at all.1-Just a little2-Quite a bit3-Very much8. I am often distracted by extraneous stimuli such as sounds or sights.0-Not at all.1-Just a little2-Quite a bit3-Very muchTotal ScoreAre you experiencing symptoms of depression?* Yes No Over the past 2 weeks how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things.0-Not at all1. Several days2-More than half the days3-Nearly every day2. Feeling down, depressed or hopelelss.0-Not at all1. Several days2-More than half the days3-Nearly every day3-Trouble falling asleep, staying asleep, or sleeping too much.0-Not at all1. Several days2-More than half the days3-Nearly every day4-Feeling tired or having little energy0-Not at all1. Several days2-More than half the days3-Nearly every day5-Poor appetitie or over eating0-Not at all1. Several days2-More than half the days3-Nearly every day6-Feeling bad about yourself-or that you're a failure or have let yourself or your family down0-Not at all1. Several days2-More than half the days3-Nearly every day7-Trouble concentrating on things, such as reading the newspaper or watching television0-Not at all1. Several days2-More than half the days3-Nearly every day8-Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figity or restless that you have been moving around a lot more than usual.0-Not at all1. Several days2-More than half the days3-Nearly every day9-Thoughts that you would be better off dead or hurting yourself in some way.0-Not at all1. Several days2-More than half the days3-Nearly every dayIf you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultTotal ScoreScoring your depression on the PHQ-9 assessment toolSelect your score range hereA score of 0 is rated as no depressionA score of 1-4 is rated as a minimal depressionA score of 5-9 is rated as a mild depressionA score of 10-14 is rated as a moderate depressionA score of 15-19 is rated as a moderately severe depressionA score of 20-27 is rated as a severe depressionAre you experiencing problems associated with alcohol or drug use or are other people complaining about your alcohol or drug use?* Yes No In the past 12 months, how many days did you drink more than a few sips of beer, wine or any drink containing alcohol? Say "0" if none.In the past 12 months, how many days did you use any Marijuana (weed, oil, or hash by smoking, vaping, or in food) or synthetic marijuana like K2, Spice) or vaping THC oil? Put 0 if none.In the past 12 months how many days did you use anything else to get high (like other illegal drugs, prescription or over-the-counter medications, and thing that you sniff, huff, or vape)? Put ) if none.Have you experienced any of the following traumas? Adults, please include your childhood experiences.* Physical Abuse Physical Neglect Sexual Abuse Emotional Abuse Witnessed Abuse Family violence Violence in your community Injured someone else. Injured or hit by a partner Incarcerated Suicide of family member or friend Murder of a family member or friend Adopted Illness of Parent Parent or caregiver with a mental illness Parent or caregiver with a drug use or too much alcohol Changes in your primary caregive as a child Unplanned pregnancy Death of a loved one Fostercare as a child Incarcerated parent Multiple moves Homelessness or problems with housing Worries about having enough food. Other I am not aware of any trauma expereinces. Height Weight What are your health risks or concerns?* Abnormal Developmental Milestones Addiction to Substances Alcoholism Asthma Blackouts Cancer Chronic Illness Chronic Pain Colitis Diabetes Type One Diabetes Type Two Disease of Female Organs Emphasemia Fasting for Weight Loss Fybromyalgia Generic Disorder Head Injury Heart Attack Hepititis High Blood Pressure HIV Hormone Problems Immunizations are unknown or not up to date. Irritable Bowel Syndrome Kidney Disorder Liver Disorder Lung Disorder Lupus Surgeries Menopause Obesity Prenatal exposure to alcohol or drugs Seizures Thyroid Problems Ulcers Vomiting for Weigth Loss Other There are no health risks known at this time. Medications* I am not currently prescribed medicatons. I am currently prescribed medicatons. How many medications are you prescribed?0123456More than 61. Medication/dosage/frequency What date did you start taking this medication? MM slash DD slash YYYY Why were you prescribed this medication? For symptoms of ADHD or ADD Depression Anxiety To stabilize my mood Hallucinations Compulsive thoughts or behaviors Delusions Which type of doctor prescribed this medication? Primary Care Physican Psychiatrist Do you take this medication as prescribed? Yes, I take this medication as prescribed. I am inconsistent and do not always take this mediation. No, I am not currently taking this medication. I am experiencing negative side effects from this medication. I am having difficulty abstaining this medication. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.If this medication does not require a follow-up appointment, please inform your therapist. MM slash DD slash YYYY 2. Medication/dosage/frequency 2. What date did you start taking this medication? MM slash DD slash YYYY 2. Which type of doctor prescribed this medication? Primary Care Physican Psychiatrist 2. Why were you prescribed this medication? For symptoms of ADHD or ADD Depression Anxiety To stabilize my mood Hallucinations Compulsive thoughts or behaviors Delusions 2. Do you take this medication as prescribed? Yes, I take this medication as prescribed. I am inconsistent and do not always take this mediation. No, I am not currently taking this medication. I am experiencing negative side effects from this medication. I am having difficulty abstaining this medication. 2. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.If this medication does not require a follow up appointment, please inform your therapist. MM slash DD slash YYYY 3. Medication/dosage/frequency 3. What date did you start taking this medication? MM slash DD slash YYYY 3. Which type of doctor prescribed this medication? Primary Care Physican Psychiatrist 3. Why were you prescribed this medication? For symptoms of ADHD or ADD Depression Anxiety To stabilize my mood Hallucinations Compulsive thoughts or behaviors Delusions 3. Do you take this medication as prescribed? Yes, I take this medication as prescribed. I am inconsistent and do not always take this mediation. No, I am not currently taking this medication. I am experiencing negative side effects from this medication. I am having difficulty abstaining this medication. 3. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.If this medication does not require a follow up appointment, please inform your therapist. MM slash DD slash YYYY 4. Medication/dosage/frequency 4. What date did you start taking this medication? MM slash DD slash YYYY 4. Why were you prescribed this medication? For symptoms of ADHD or ADD Depression Anxiety To stabilize my mood Hallucinations Compulsive thoughts or behaviors Delusions 4. Which type of doctor prescribed this medication? Primary Care Physican Psychiatrist 4. Do you take this medication as prescribed? Yes, I take this medication as prescribed. I am inconsistent and do not always take this mediation. No, I am not currently taking this medication. I am experiencing negative side effects from this medication. I am having difficulty abstaining this medication. 4. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.If this medication does not require a follow up appointment, please inform your therapist. MM slash DD slash YYYY 5. Medication/dosage/frequency 5. What date did you start taking this medication? MM slash DD slash YYYY 5. Which type of doctor prescribed this medication? Primary Care Physican Psychiatrist 5. Why were you prescribed this medication? For symptoms of ADHD or ADD Depression Anxiety To stabilize my mood Hallucinations Compulsive thoughts or behaviors Delusions 5. Do you take this medication as prescribed? Yes, I take this medication as prescribed. I am inconsistent and do not always take this mediation. No, I am not currently taking this medication. I am experiencing negative side effects from this medication. I am having difficulty abstaining this medication. 5. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.If this medication does not require a follow up appointment, please inform your therapist. MM slash DD slash YYYY 6.Medication/dosage/frequency 6. What date did you start taking this medication? MM slash DD slash YYYY 6. Which type of doctor prescribed this medication? Primary Care Physican Psychiatrist 6. Why were you prescribed this medication? For symptoms of ADHD or ADD Depression Anxiety To stabilize my mood Hallucinations Compulsive thoughts or behaviors Delusions 6. Do you take this medication as prescribed? Yes, I take this medication as prescribed. I am inconsistent and do not always take this mediation. No, I am not currently taking this medication. I am experiencing negative side effects from this medication. I am having difficulty abstaining this medication. 6. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.If this medication does not require a follow up appointment, please inform your therapist. MM slash DD slash YYYY 7 or more medicationsPlease provide the requested information for you remaining prescriptions.Sleep Habits* My sleep is within normal range. I don't get enougn sleep. I sleep too much Diet* I eat a balanced healthy diet. I eat a lot of junk food. I over eat. I worry about my diet. I skip meals. Activity Level* I prefer physically actives like walking or playing a sport. I prefer passive activies like TV, reading & video games Nicotine Use* I smoke cigarettes. I use dip or chewing tobacco products. I use e-cigarettes. My parents or caregiver suspects I use nicotine. I do not use tobacco products Substance Use* I have recently participated in recreational substance use. I have participated in recreational substance use in the past. My parents or guardian suspect I use recreational substances. I have never participated in recreational substance use. Alcohol Use* I use alcohol occasionally or regularly. I have used alcohol in the past. I have never used alcohol. My parents or guardian suspects alcohol use. I chose to not drink alcohol. Alcohol Use*Check all that apply. I drink alcohol occasionally or regularly. I get intoxicated occasionally or regularly I used to have a drinking problem I am concerned that my alcohol use maybe a problem I chose to not drink alcohol. I have had alcohol related arrests. Sexuality Identity and Orientation* Biological Male Biological Female Hermaphrodite Identify myself as a male Identifiy myself as a female I have a non-binary gender identitiy Heterosexual Homosexual Bisexual Pan Sexual A-sexual Transgender Undeterminend Other Sexual Activity* I am sexually active I am not sexually active I am experincing sexual functioning problems. unknown Have you started Puberty yet?* Yes No Unknown Do you have access to birth control or know how to obtain it?* Yes No What is your current grade level?* How is your grade performance? My grades are average My grades are below normal My grades are above average What is your highest level of education?* Grade school Middle school Some high school GED High school graduate Trade school Some college Associates degree College graduate Masters degree Doctorate or PH. D. Major or area of specialty Name of School Behavioral Impact on Education IEP 504 Plan Classroom accommodations truancy/ attendance suspension/discipline alternate school placements home school advanced program, not attending school other No known impact on education Language and Communication* I have hearing needs I have vision needs English is my second language I have a preference for a language other than English. I need a translator I have problems communicating I use aids to communicate I don't have communication needs. Vocational and Employment* I have self care skills appropriate for my age. I would benefit from skills training. I have career goals I am employed Vocational and Employoment* I am employed I am unemployed. Unemployment is a problem for me. I enjoy my job/career I am experincing work related problems. I would benefit from Vocational Rehabilitation Services I am active duty or retired military. Where do you work and what do you do?* Legal* Custody order DJJ envolvement CDW DCBS custody Legal offenses Client has a legal representative No known legal history CPS involvement/ open CPS case Legal* Custody order Divorce Civil suite Probation or Parole Children in DCBS custody Legal offenses I have an attorney or a legal representative Cilhd Protective Serviceis is involved with my family No legal history or civil suits or arrests Disability Determination* I am applying for Social Security Disability. I am receiving Social Security Disability I have no plans to apply for Social Security Disability Financial Resources* My financial resources are adequate to meet the needs of myself and my family. I would benefit from resource assistance such as food and housing. I am homeless. Social Relationships* I have difficulty developing pro-social skills with peers. i have difficulty developing pro-social skills with authority figurues. I have difficult with intimate partner relationship skills. My social skills are not a concern. Culture and Ethnicity* White Black American Indian Hispanic or Latino Other I identify with the white majority culture. I identify with a minotrity culture. My ethnicity is.....* My minority is group is......* Recreational and Leisure Skills/Strengths* I have hobbies and special interests I have lost interest in my hobbies and interests. Describe the hobbies and things you have enjoyed doing now or in the past .* Spirituality and Religion* I am active with a religious organization I experience spirituality or religion as a sigificant resource of support. I do not see spirituality or religion as a significant resource or support I experienced religious abuse What is the name of your religious organization? I would describe my community or neighborhood as Stable Distressed Threatening Environmental Factors for Home Based Services: I have the following in my home* Dog(s) in the home Cat(s) in the home Bird(s) in the home Cigarettes are used in my home Gun(s) or other weapons in my home Illegal activities in my home Recent domestic violence in my family Bed bugs in my home Other: There are no known allergens or risk factors in my home or place of residence. SED Determination Criteria*Your provider will complete the following assessment questions with you to see if you are eligible for added services. You can help by checking any problems you experience. Significant problems with my thoughts, mood, perception, orientation, memory or behavior Significant Impaired functioning in self-care Significant impaired functioning in interpersonal relationships Impaired functioning family life Impaired functioning at school Impaired functioning in self direction And symptoms have persisted for one year or are judged to be at high risk for continuing for one year And/or DCBS has removed the child from the home and has been unable to maintain in a stable setting due to emotional instability None of the above Name of the person who provided this information* First Last Email Enter the email address given to you by your provider. You may upload a current copy of your insurance card here.Max. file size: 32 MB.Submission ID
