Patient Health Questionnaire

Mental Health History & Presenting Concerns
Patient/Client Name

First NameLast Name
Date of Birth

MonthDayYear
Preferred Pronoun
Social Security Number
State of IL RIN number (9-digit)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please check the box below if this address is a Community Integrated Living Arrangement (CILA)

CILA
Patient/Client Phone Number

Area CodePhone Number
Patient/Client Email
example@example.com
Are you your own legal guardian?
Emergency/Guardian Name

First NameLast Name
Emergency/Guardian Number

Area CodePhone Number
Emergency/Guardian Email
example@example.com
Do you authorize communication via text?
Please indicate yours (or loved one's) CURRENT diagnoses:*

Autism Spectrum Disorder (ASD)Intellectual DisabilityAdjustment DisorderAnxietyDepressionBipolarAttention-deficit/hyperactivity disorder (ADHD)Other
Please select any diagnoses you would like to explore for yourself or your loved one:

Autism Spectrum Disorder (ASD)Intellectual DisabilityAdjustment DisorderAnxietyDepressionBipolarAttention-deficit/hyperactivity disorder (ADHD)Other

Over the last 2 weeks, how often have you, or your loved one, been bothered by or experienced any of the following problems?

	Not at all-0	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
10. Panic attacks, or feeling so paralyzed you cannot move
11. Avoiding responsibilities
12. Use substances (e.g., alcohol, marijuana, etc.), either to pass time or to better manage your symptoms

How difficult have the above experiences made it for you, or your child, to do your/their work, take care of things at home, or get along with other people?

	1	2	3	4	5

1 is Not difficult, 5 is Very difficult

What are you, or your child's, current coping strategies or activities that you/they have done to feel better or deal with the above-mentioned challenges?
What brings you to counseling today?
Have you/your child participated in counseling in the past?
If YES, when?
Is the patient taking psychotropic medications?
If YES, write the name(s) below
Name of Prescribing Physician
Has the patient ever been admitted to a hospital/facility for psychiatric care?
If YES, include Month/Year

Mental Health History & Presenting Concerns

Strengths & Challenges

Consent for Initial Appointment