To ensure we provide you with the best possible mental health services, we kindly ask you to complete this questionnaire.
It should take about 30 minutes, so please find a quiet place where you can focus without interruptions. Your honest and thorough responses will help us get to know you better and tailor our services to your needs.
Rest assured, all information you provide will be kept confidential in accordance with state and federal law.
In this section, we gather information about your current marital status and family dynamics. Understanding your relationships and household composition helps us provide personalized and effective mental health support.
In this section, we focus on the specific concerns that have brought you to seek mental health services.
Please check any symptoms or experiences that you have had in the last month
We aim to gather comprehensive information about your past experiences with mental health professionals, psychiatric medications, hospitalizations, and any existing medical conditions.
Understanding your medical history allows us to assess how your physical health may intersect with your mental well-being and ensure that we provide comprehensive care.
By gathering information about your family members' health, relationships, and any history of mental illness, we can better assess your risk factors and tailor our support accordingly.
If so, please give the persona’s name and relationship to you
By learning about your past experiences in these areas, we can gain insights into your overall well-being and identify any factors that may impact your mental health.
If Yes, please describe
By gathering information about your alcohol, tobacco, and drug use habits, as well as any related behaviors or concerns, we can better understand your overall health and provide appropriate support.
Please indicate for each drug listed below
We invite you to share any other details that you believe are relevant to your mental health and well-being. This could include anything not covered in previous sections, such as unique personal experiences, specific concerns, or additional context that you feel is important for us to know.
Thank you for taking the time to complete this questionnaire. Please be assured that all the information you provide is strictly confidential and will be used solely to better understand and monitor your case, allowing us to offer the most effective treatment possible. We greatly value your time and honesty in sharing these details with us.
