YOUTH INITIAL SURVEY
NAME
DATE
/
Month
/
Day
Year
Date
How do I identify?
Male
Female
What is your age?
What is your birth date?
-
Month
-
Day
Year
Date
What grade are you in school?
What school do you attend?
What city and state do you live in?
Select the following that you use to describe yourself, your race, or ethinicity:
Black or African American
White, not Hispanic
Hispanic or Latino/a
Asian/Pacific Islander
American Indian or Alaskan Native
Other
Have you seen a mental health professional before?
Yes
No
Specify all medications and supplements you are presently taking and for what reason:
Do you drink alcohol?
Yes
No
Do you use recreational drugs?
Yes
No
Are you affiliated with a gang?
Yes
No
Do you have suicidal thoughts?
Yes
No
Have you ever attempted suicide?
Yes
No
Do you have thoughts or urges to harm others?
Yes
No
Have you ever been hospitalized for a psychiatric issue?
Yes
No
Is there a history of mental illness in your family?
Yes
No
I don't know
Who do you live with?
Please check any of the following you have experienced in the past six months:
Increased appetite
Difficulty sleeping
Decreased appetite
Excessive sleep
Low motivation
Trouble concentrating
Isolation from others
Fatigue/low energy
Low self-esteem
Depressed mood
Anxiety
Tearful or crying spells
Fear
Hopelessness
Panic
Other
Please check any of the following that you may have experienced in the last 6 months:
Headache
High blood pressure
Gastritis or esophagitis
Hormone-related problems
Head injury
Angina or chest pain
Irritable bowel
Chronic pain
Loss of consciousness
Heart attach
Bone or joint problems
Seizures
Kidney-related issues
Chronic fatigue
Dizziness
Faintness
Heart valve problems
Urinary tract problems
Numbness & tingling
Fibromyalgia
Diabetes
Shortness of breath
Hepatitis
Asthma
Arthritis
Thyroid issues
HIV/AIDS
Cancer
Other
What are your favorite things to do?
What else would you like the therapist to know?
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