Assessment: PHQ-9 Modified (12-18 years)
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling down, depressed, irritable or hopeless:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
2. Little interest or pleasure in doing things:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
3. Trouble falling asleep, staying asleep, or sleeping too much:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
4. Poor appetite, weight loss or overeating:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
5. Feeling tired, or having little energy:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
6. Feeling bad about yourself- or feeling that you are a failure, or that you have let yourself or your family down:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
7. Trouble concentrating on things like school work, reading, or watching TV:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you were moving around a lot more than usual:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself in some way:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
Please Select
Yes
No
If you are experiencing any of the problems on this form, 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?
Please Select
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Has there been a time in the past month when you have had serious thoughts about ending your life?
Please Select
Yes
No
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?
Please Select
Yes
No
Submit
Should be Empty: