Please complete the form below
    1. Section A – Please circle “yes” or “no” for each question. 1. Have you been consistently depressed or down, most of the day, nearly every day, for the past two weeks? YesNo 2. In the past two weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time? YesNo 3. Have you felt sad, low, or depressed most of the time for the last two years? YesNo 4. In the past month, did you think that you would be better off dead or wish you were dead?. YesNo 5. Have you ever had a period of time when you were feeling up, hyper, or so full of energy or full of yourself that you got into trouble, or that other people thought you were not your usual self? (Do not consider times when you were intoxicated on drugs or alcohol.) YesNo 6. Have you ever been so irritable, grouchy, or annoyed for several days, that you had arguments,had verbal or physical fights, or shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted, compared to other people, even when you thought you were right to act this way?. YesNo Section B – Please circle “yes” or “no” for each question. 7. Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable, or uneasy, even when most people would not feel that way? Did these intense feelings get to be their worst within ten minutes? (If the answer to both questions is “yes,” circle “yes”; otherwise, circle “no.”). YesNo 8. Do you feel anxious or uneasy in places or situations where you might have the panic-like symptoms we just spoke about? Or do you feel anxious or uneasy in situations where help might not be available or escape might be difficult? Examples:  being in a crowd,  standing in a line,  being alone away from home or alone at home,  crossing a bridge,  traveling in a bus, train, or car? YesNo 9. Have you worried excessively or been anxious about several things over the past six months? (If you answer “no” to this question, answer “no” to Question 10 and proceed to Question 11.) YesNo 10. Are these worries present on most days? YesNo 11. In the past month, were you afraid or embarrassed when others were watching you or when you were the focus of attention? Were you afraid of being humiliated? Examples:  speaking in public,  eating in public or with others,  writing while someone watches,  being in social situations. YesNo 12. In the past month, have you been bothered by thoughts, impulses, or images that you couldn’t get rid of that were unwanted, distasteful, inappropriate, intrusive, or distressing? Examples:  being afraid that you would act on some impulse that would be really shocking,  worrying a lot about being dirty, contaminated, or having germs,  worrying a lot about contaminating others, or that you would harm someone even though you didn’t want to,  having fears or superstitions that you would be responsible for things going wrong,  being obsessed with sexual thoughts, images, or impulses,  hoarding or collecting lots of things,  having religious obsessions. YesNo 13. In the past month, did you do something repeatedly without being able to resist doing it? Examples:  washing or cleaning excessively,  counting or checking things over and over,  repeating, collecting, or arranging things,  other superstitious rituals. YesNo 14. Have you ever experienced, witnessed, or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else? Examples:  serious accidents,  sexual or physical assault,  terrorist attack,  being held hostage,  kidnapping,  fire,  discovering a body,  sudden death of someone close to you,  war, natural disaster. YesNo 15. Have you re-experienced the awful event in a distressing way in the past month? Examples:  dreams,  intense recollections,  flashbacks,  physical reactions. YesNo Section C – Please circle “yes” or “no” for each question. 16. Have you ever believed that people were spying on you, or that someone was plotting against you, or trying to hurt you? YesNo 17. Have you ever believed that someone was reading your mind or could hear your thoughts, or that you could actually read someone’s mind or hear what another person was thinking? YesNo 18. Have you ever believed that someone or some force outside of yourself put thoughts in your mind that were not your own, or made you act in a way that was not your usual self? Or, have you ever felt that you were possessed? YesNo 19. Have you ever believed that you were being sent special messages through the TV, radio, or newspaper? Did you believe that someone you did not personally know was particularly interested in you? YesNo 20. Have your relatives or friends ever considered any of your beliefs strange or unusual? YesNo 21. Have you ever heard things other people couldn’t hear, such as voices? YesNo 22. Have you ever had visions when you were awake or have you ever seen things, other people couldn’t see? YesNo By submitting this form, the provider acknowledges all information provided was at the consent of the client (family) and caregiver & intended solely for treatment purposes.

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