Initial Questionnaire

    Employment Status
    Full-TimePart-TimeFull-Time StudentPart-Time StudentUnemployedOther

    Current Symptoms (Check all that apply)
    Depressed moodAppetite ChangesMind RacingAnxiety/WorryIrritabilitySuspicious of othersPanic AttacksFatigueSchool/Work ProblemsSleep ProblemsFeelings of GuiltFinancial StressCan't Enjoy ActivitiesRelational ProblemsPoor ConcentrationImpulsive BehaviorOthers

    Any thoughts/feelings of wanting to hurt or kill yourself (past or present)?Yes, In the PastYes, CurrentlyNo

    Any current or past self-injurious behavior (cutting, burning, etc.)?
    Past: YesNo
    Present: YesNo

    Have you received mental health services in the past? (Check all that apply)
    PsychotherapyMedication ManagementGroup TherapyOutpatientInpatientPsychiatricOtherNone

    Name of provider/facility, Location of treatment, Approximate dates of treatment & Reason for treatment

    Medical History