Labor and Industries Intake with Whodas, GAD-7 and PHQ-9 (Archived)

Labor and Industries Intake with Whodas, GAD-7 & PHQ-9
Daniels-Brown Counseling PLLC
822 E Cherry Ave.
Moses Lake, WA. 98837
Phone: (509) 766-1878 Fax: (509) 581-4370
Email: office@danielsbrowncounseling.com
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Mailing Address
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Birth Date

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Emergency Contact Name
Emergency Contact Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
CLAIM INFORMATION
Claim Number
Insured by (L&I, Penser, other)
Claim Manager's Name
Claim Manager's Phone Number
Referring Provider Name and Number
Date of Injury

MonthDayYear
Date
Describe injury:
Treatment to this point
In your Opinion what have been the psychological effects of the injury treatments
*My signature on this form indicates my agreement to participate in treatment related to my claim and authorizes contact between Glade Daniels-Brown, my treating physician, and the insurance company staff.

*I agree to participate in treatment to the best of my abilities, including completing weekly homework assignments and reading.

*My signature on this form authorizes the release of medical information necessary to process this claim for payment through my insurance carrier and/or to my treating provider.

*I am responsible for a $95 No-Show fee if I fail to show up for my appointment or if I call and cancel less than 24 hours before my appointment.
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Daniels-Brown Counseling PLLC
822 E Cherry Ave.
Moses Lake, WA. 98837
Phone: (509) 766-1878 Fax: (509) 581-4370
Email: office@danielsbrowncounseling.com
AUTHORIZATION FOR EXCHANGE OF INFORMATION
Name
Today's Date

MonthDayYear
Date
Gender
Birth Date

MonthDayYear
Date
Mailing Address
City
State
Zip
Emergency Contact Name
Emergency Contact Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
My signature on this form authorizes contact and information sharing between Daniels-Brown Counseling and the parties below:
Name
Address
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Continuity of CareLabor and Industries ClaimAttorneyNext of Kin/AdvocateSocial Services ProviderEducationalDrug and Alcohol TxOther
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Limits of Exchange
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Dates of Reauthorization
Date

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Initial
Date

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Date
Initial
WHODAS 2.0
Claim number
Name
Today's Date

MonthDayYear
Date
World Health Organization Disability Assessment Schedule 2.0

This questionnaire asks about difficulties due to health/mental health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long-lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please select only one response.

In the past 30 days, how much difficulty did you have in:*

Rows	None(1)	Mild(2)	Moderate (3)	Severe(4)	Extreme or Cannot Do(5)
Standing for long periods such as 30 minutes?
Taking care of your household responsibilities?
Learning a new task, for example, learning how to get to a new place?
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health problems?
Concentrating on doing something for ten minutes?
Walking a long distance such as a kilometer [or equivalent]? 1 kil = .62 miles
Washing your whole body?
Getting dressed?
Dealing with people you do not know?
Maintaining a friendship?
Your day-to-day work?

Overall, in the past 30 days were these difficulties present?*
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition*
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut or reduce your usual activities or work because of any health condition?*
GAD-7

Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious or on edge*
2. Not being able to stop or control worrying*
3. Worrying too much about different things*
4. Trouble Relaxing*
5. Being so restless that it is hard to sit still*
6. Becoming easily annoyed or irritable*
7. Feeling afraid as if something awful might happen*
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
Full Name*
DATE*

MonthDayYear
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things*
2. Feeling down, depressed, or hopeless*
3. Trouble falling or staying asleep, or 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 fidgety 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 in some way*
If you checked off any problems. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*
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Labor and Industries Intake with Whodas, GAD-7 & PHQ-9

CLAIM INFORMATION

AUTHORIZATION FOR EXCHANGE OF INFORMATION

My signature on this form authorizes contact and information sharing between Daniels-Brown Counseling and the parties below:

Dates of Reauthorization

WHODAS 2.0

GAD-7

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?