DEPRESSION

Assessment

Our Client Intake and Assessment Forms are designed to assist us in knowing more about you, your background, and what specific needs you wish to address.   Any information received from these forms will be used for the expressed purpose of assisting you achieve your desired goals and is strictly confidential.

DEMOGRAPHIC ASSESSMENT

5. Explain your depression treatment history

6. Explain your bipolar disorder treatment history

7. Explain your generalized anxiety treatment history

8. Explain your post-traumatic disorder stress treatment history

4. Select your ethnicity/racial group:

3. What is your marital status?

2. What is your gender?

1. What is your age?

6. Been feeling blue?

9. Thought about or wanted to commit suicide?

5. Been feeling hopeless about the future?

2. Been blaming yourself for things?

1. Been Feeling low in energy, slowed down?

DEPRESSION ASSESSMENT

The depression screening questions are presented below. Select one option for each question that comes closest to your answer

Over the past two weeks, how often have you:

3. Had poor appetite?

4. Had difficulty falling asleep, staying asleep?

7. Been feeling no interest in things?

8. Had feelings of worthlessness?

10. Had difficulty concentrating or making decisions?

11. Have you ever had a week or more of sustained, unusually elevated mood, like a "high," out-of-control behavior (such as risky sex, over-spending), racing thoughts, and little need for sleep?

11. Have you ever had a week or more of sustained, excessively irritable mood, with anger, arguments, or breaking things that led difficulties with others?

11. Have you ever had any close blood relative (parent, child, sister, brother) with depression, bipolar disorder, alcohol abuse, or who was psychiatrically hospitalized?

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18 - 25
26 - 35
36 - 50
51 - 64
65 and above
No response

MaleFemaleNo response

I am married or living with a partner
I am divorced or separated
I have never married
I am widowed
No response

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Multi-Racial or Other
No response

I am currently being treated
I have received treatment in the past
I have never been treated

I am currently being treated
I have received treatment in the past
I have never been treated

I am currently being treated
I have received treatment in the past
I have never been treated

I am currently being treated
I have received treatment in the past
I have never been treated

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

For none or little of the time
For some of the time
For most of the time
For all of the time

a) Never
b) More than 6 months ago
c) In the past past 6 months
Both b and c

a) Never
b) More than 6 months ago
c) In the past past 6 months
Both b and c

Yes
No
Don't Know