Bipolar Disorder

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?

1. you felt so good or so hyper that other people thought  you were not your normal self or you were so hyper that you got into trouble.

Bipolar Disorder Assessment

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

Has there ever been a period of time when you were not your usual self and...

2. you were so irritable that you shouted at people or started fights or arguments?

3. you felt much more self-confident than usual?

4. you got much less sleep than usual and found you didn't really miss it?

5. you were much more talkative or spoke much faster than than usual?

6. thoughts raced through your head or you couldn't slow your mind down?

7. you were so easily distracted by things around you that you had trouble concentrating or staying on track?

8. you were much more active or did many more things than usual?

9. you were much more interested in sex than usual?

10. you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

11. spending money got you or your family into trouble?

A) If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

B) How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles; getting into arguments or fights?

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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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No
I did not answer YES to more than one

No problem
Minor problem
Moderate problem
Serious problem
I did not answer YES to more than 1