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Client's Name *

First Name

Last Name

Client's date of birth *

MM

DD

YYYY

Client's legal sex *

Female

Male

Other

Prefer not to answer

Client's primary phone number *

(###)

###

####

Is it okay to leave a message at this number? *

Yes

No

Do you (client) have a conservator (i.e., someone legally assigned to make decisions for you)? *

Yes

No

Have you (client) engaged in any self-injurious behavior (such as cutting or burning) in the past 3 months? *

Yes

No

In the past 3 months, have you (client) done anything to prepare for or attempt suicide? *

Yes

No

Have you (client) ever been hospitalized with any of the following: (check all that apply) *

Autism

Bipolar Disorder

Schizophrenia or Schizoaffective Disorder

Anorexia or Bulimia

None of the above

In the past 3 months, how often have you (client) used ANY alcohol or drugs, on average? *Include alcohol, cannabis even if prescribed, and recreational drugs *

Not at all

About once per month

2-4 times per month

2-3 time per week

Once per day

More than once per day

Are you (client) able to do daily activities, such as go to work/school, showering, eating, and sleeping? *

No problems with these activities

Mild problems (e.g., mild sleep difficulties, low appetite)

Moderate problems

Marked problems (e.g., missing days of work or school, moderate difficulty leaving the home)

Severe problems (e.g., not able to work or go to school, sleeping less than 4-5 hours per night, not able to leave home, showering less than once per week)

*Telehealth Note: You must be located in a state that is fully participating in PSYPACT legislation at the time of your appointment. *

I understand and agree to comply with this rule.