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90 Day Assessment
22
Questions
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1
Name of Client
First Name
Last Name
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2
Is someone other than the client filling out this assessment on behalf of the client?
YES
NO
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3
Name of person filling out assessment on behalf of client
First Name
Last Name
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4
Name of Provider/Therapist
If more than one, choose all that currently apply
Debra Erickson
Jordan Hofmann
Abby Gleason
Alexis Bloomfield
Amanda Schmidt
CeCe Bacon
Chantal Kohl
Cheryl Lockett
Christopher Sanders
Christy Freehling
Cindy Betka
Dave Hoyt
Emma Todd
Laurie Robinson
Raquel Moreno-Izaguirre
Sara Gasper
Sarah Bennett
Suzanne Riley
Alivation Health- Telehealth
Other
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5
Little interest or lack of pleasure in doing things you normally would enjoy?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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6
Feeling down, depressed, or hopeless?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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7
Feeling more irritated, grouchy, or angry than usual?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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8
Starting more projects than usual or doing more costly or risky things than usual?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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9
Feeling nervous, anxious, worried, or on edge?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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10
Feeling panic or being frightened?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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11
Avoiding situations that make you anxious?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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12
Unexplained aches and pains?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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13
Unwanted thoughts, urges, or images that repeatedly enter your mind?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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14
Feeling detached or distant from yourself, your surroundings, or your memories?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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15
Not knowing who you are or what you want out of life?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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16
Not feeling close to other people of enjoying relationships with others?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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17
Drinking over 4 alcoholic drinks in one day?
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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18
Using any mind altering substances?
This could include illegal drugs or medication not prescribed to you
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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19
Smoking or chewing tobacco of any form?
This could include illegal drugs or medication not prescribed to you
None
Slight (rarely, less than 1-2 days)
Mild (several days, 2-7)
Moderate (more than 7 days)
Severe (nearly every day)
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20
Please answer the following questions related to your own progress
How well do you manage relationships in your life?
How well are you managing your daily mental health and stress levels?
How well are you setting boundaries in your life?
How well do you communicate your needs and feelings to those in your life?
How well do you think you are accomplishing your initial goals for therapy?
How well do you manage relationships in your life?
How well are you managing your daily mental health and stress levels?
How well are you setting boundaries in your life?
How well do you communicate your needs and feelings to those in your life?
How well do you think you are accomplishing your initial goals for therapy?
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21
How well are we doing?
1.... not satisfied.... 5 somewhat satisfied.... 10 very satisfied
How well do we assist with scheduling appointments with our office?
How would you describe the process of communication with our office?
How have you felt about the helpfulness of our staff?
How would you describe the friendliness of staff?
How do you feel about the connection with your provider?
How satisfied are you with your provider in listening to you and helping you achieve your goals?
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How well do we assist with scheduling appointments with our office?
How would you describe the process of communication with our office?
How have you felt about the helpfulness of our staff?
How would you describe the friendliness of staff?
How do you feel about the connection with your provider?
How satisfied are you with your provider in listening to you and helping you achieve your goals?
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22
Is there anything you are specifically happy with or appreciate about our office? Is there anything we could do better or change?
We are constantly working to improve our services to better assist you, your feedback is extremely helpful!
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