Routine Mental Health Screening Tool
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Insurance
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Marital Status
Please Select
Single
In A Relationship
Living Together
Married
Separated
Divorced
Gender
Race
Initial Contact Date
-
Month
-
Day
Year
Date
Availability
Pharmacy
Allergies
Food and Medicine
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Court Ordered?
Yes
No
Judge
Next Scheduled Court Date
-
Month
-
Day
Year
Date
Concern
Please Select
Anger Management
Mental Health
Drugs / Alcohol
Parenting
Are you a former client?
Yes
No
If Yes, who was your clinician?
Who referred you to us?
Identified Routine Care Area
Rows
Yes
No
Additional Information
Do you have a mental health diagnosis?
Are you currently under mental health care?
Are you on any mental health medications? (if yes, who is prescribing them, Px or PCP)
Are you taking your medications as prescribed?
Are you stable on your medication in your opinion?
There is a $50 no-show fee
*
I accept and agree to receive text message reminders.
For Office Use Only: Make two (2) attempts to contact the client and detail below.
Rows
Date
Time
Results
Client Contact Attempt #1
Client Contact Attempt #2
Client Contact Attempt #3
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