Mental Health Integration

Adult

Date: _______________ Patient’s Name________________________________ Date of Birth ___________________

1. What are your main concerns and/or symptoms that you are dealing with at this time?
a. Physical: ___________________________________________________________________________________
b. Emotional:__________________________________________________________________________________
2. What is currently causing you stress (at home, school, or work; in relationships)?

3. What goals do you hope to achieve with this treatment?

4. Have you been treated for mental health in the past? Complete the table below. Include any type of outpatient or
inpatient treatment or therapy you received. Be sure to list all medications you have tried.

Mental Health Problem/Treatment

Psychiatric Hospitalizations? Include date, situation, treatment provided

Suicide attempt? Include date, situation, treatment provided

Prior experience with therapy? Include dates, who provided treatment

Current Mental Health Medications

Name and dose of Date Started Response/Side Effects Are you still on
Medications it?

Yes No

Yes No
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Adult

Yes No

Yes No

Yes No
5. Physical Review of Symptoms. Are you currently experiencing any of the following? (Select all that apply):

Chest Pain Shortness of Breath Tension Headache

Fatigue Back Pain Migraine Headache
Dizziness Stomachache Irritable Bowel Syndrome
Obesity Head Injury Asthma
Fibromyalgia Diabetes High Blood Pressure

6. Chronic Pain Assessment –

a. Have you had pain every day for the last 6 months or longer? Yes No
b. If yes, rate your average daily level of pain on a scale of 0-10 (using the pain scale below), with 0 being no
pain and 10 being most severe. ___________
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Adult

7. Family history and critical events

a. Family history of mental health diagnosis: Do you have any biological relatives who have had behavioral,
emotional, or mental problems such as depression, anxiety, bipolar disorder, ADHD, drug or alcohol use
disorder, or suicide? If yes, complete the table below.
Relative (parent, sibling, child) Behavioral, emotional, or mental problem

b. Critical Events- Check if any of the following critical events have occurred in your family:

Event Age Comments

 Parent or sibling illness
 Parental separation
 Parental divorce
 Family move
 Financial stress
 Out-of-home placement
 Death in family
 Death of close friend
 Other:

8. Access to Firearms: Do you have access to firearms? Yes No

a. If “Yes”, how are firearms secured? _____________________________________________________
9. Lifestyle, strengths/weaknesses, and goals:
a. On average, how many days per week do you perform moderate/vigorous exercise or physical activity?
____________
b. On average, how many minutes of moderate/vigorous exercise or physical activity do you perform on each of
those days? __________
c. At what intensity (how hard) do you usually exercise?
Light (casual walk) Moderate (brisk walk) Vigorous (jog/run)
d. List your strengths and weaknesses: (What are you good at? What are somethings that are difficult for you?)
My strengths My weaknesses
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Adult

Depression Screening (PHQ-9)

Are you currently: on medication for depression not on medication for depression not sure in counseling

Over the last 2 weeks, how often have you been bothered by any of Several More than Nearly
the following problems? Not at all days half the days every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling/staying asleep, sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

Feeling bad about yourself — or that you’re a failure or

6. have let yourself or your family down 0 1 2 3

Trouble concentrating on things, such as reading the

7. newspaper or watching television 0 1 2 3

Moving or speaking so slowly that other people could

8. have noticed, or the opposite — being so fidgety or 0 1 2 3
restless that you have been moving around a lot more
than usual
Thoughts that you would be better off dead or of hurting
9. yourself in some way 0 1 2 3

10. 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?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
In the past 2 years, have you felt depressed or sad most days, even if you felt okay sometimes?
Yes No
Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes No

Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?

Yes No
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Anxiety and Stress Disorder Symptoms:

Are you currently: on medication for mood regulation not on medication not sure in counseling

Over the last 2 weeks, how often have the problems below bothered you? Check the number for each item.

How Often

More than half Nearly every

Generalized Anxiety Disorder (GAD-7) Not at all Several days
the days day

Feeling nervous, anxious, or on edge? 0 1 2 3

Not being able to stop or control worrying? 0 1 2 3
Worrying too much about different things? 0 1 2 3
Trouble relaxing? 0 1 2 3
Being so restless that it is hard to sit still? 0 1 2 3
Becoming easily annoyed or irritable? 0 1 2 3
Feeling afraid as if something awful might happen? 0 1 2 3

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?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

More
Other Symptoms Several Nearly
Not at all than half
days every day
the days

Panic: This can include increased heart rate, increased blood pressure, chest
pain or pressure, irregular breathing, getting lightheaded 0 1 2 3

Obsessions and/or compulsions: This can include repeated or persistent

thoughts that they can’t control (about germs, schoolwork, being perfect,
neatness, safety, death); repeated behaviors or extreme routines that they 0 1 2 3
can’t control (such as repeated handwashing, checking locks, cleaning,
personal hygiene)
Hallucinations: This can include hearing voices or seeing things that others
don’t hear or see. 0 1 2 3

Symptom duration: Symptoms have been of serious concern for (check the appropriate time period):
2 to 4 weeks 1 to 3 months 3 to 6 months 6 months to 1 year 1 to 2 years More than 2 years
Have 2 or more of these symptoms lasted longer than 1 year? Yes No
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Sleep Evaluation Questions

Do you have problems sleeping? If no, skip this section. If yes, answer the following:

Insomnia Problem None Mild Moderate Severe Very

Severe
Difficulty falling asleep 0 1 2 3 4

Difficulty staying asleep 0 1 2 3 4

Problems waking up too early 0 1 2 3 4

How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?

Very Satisfied Moderately Dissatisfied Very

Satisfied Satisfied Dissatisfied

0 1 2 3 4

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

Not at all A little Somewhat Much Very Much

Noticeable Noticeable

0 1 2 3 4

How WORRIED/DISTRESSED are you about your current sleep problem?

Not at all A little Somewhat Much Very Much

Worried Worried

0 1 2 3 4

To what extent do you consider your sleep problems to INTERFERE with your daily functioning? (e.g. daytime fatigue,
mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

Not at all A little Somewhat Much Very Much

Interfering Interfering

0 1 2 3 4
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Adult

Abuse and Traumatic Events.

1. Current events. Check any events below that you are currently experiencing:
Physical abuse Physical Neglect
Emotional Abuse Traumatic Events
Sexual Abuse Drug abuse in the Family
Emotional Neglect None of the above

2. Past Events. Check any events below that you have experienced in the past:
Physical abuse Physical Neglect
Emotional Abuse Traumatic Events
Sexual Abuse Drug abuse in the Family
Emotional Neglect None of the above

3. Now, answer the following questions about the items you checked above:
a. Are any of the situations occurring now? Yes No
b. Are these situations still affecting you? Yes No
c. Do you feel in any danger or at risk because of these issues? Yes No
d. Have you sought help from a professional to deal with any of these issues? Yes No
- If so, who? ___________________________________________________
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Adult

ADHD Self Report Scale Symptom Checklist

For each question below, click in the box that best describes how you have felt and acted over the past 6 months

Sometimes

Very Often
Rarely
Never

Often
1.How often do you have trouble wrapping up the final details of a project, once the
challenging parts have been done?

2. How often do you have difficulty getting things in order when you have to do a task
that requires organization?
3. How often do you have problems remembering appointments or obligations?

4. When you have a task that requires a lot of thought, how often do you avoid or delay
getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit
down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven
by a motor?

7. How often do you make careless mistakes when you have to work on a boring or
difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring
or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even
when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?

11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are
expected to remain seated?
13. How often do you feel restless or fidgety?

14. How often do you have difficulty unwinding and relaxing when you have time to
yourself?
15. How often do you find yourself talking too much when you are in social situations?

16. When you’re in a conversation, how often do you find yourself finishing the
sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is
required?
18. How often do you interrupt others when they are busy?
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Adult

Eating Behaviors
Questions Yes No Questions Yes No
Are you concerned with your Does your weight affect the way
eating patterns? you feel about yourself?

Have any members of your family

Do you ever eat in secret?
suffered from an eating disorder?

Alcohol or Drug Use (NIDA)

Monthly
Once or

Daily or
Weekly

Almost
In the past year, how often have you used the following?

Never

Twice

Daily
Alcohol:
- For men, less than or equal to 5 standard drinks* per day
- For women, less than or equal to 4 standard drinks* per
day

Tobacco products (including e-cigarettes)

Prescription Medications for non-medical reasons

Prescription medications in amounts greater than prescribed, for

reasons other than prescribed, or if not prescribed to you
Illegal drugs (illicit, street drugs)

*Definition of a “standard drink”:

- Beer or wine cooler (5% alcohol): 12 oz - Table wine (12% alcohol): 5 oz
- Malt Liquor (7% alcohol): 8-9 oz - 80-proof spirits (hard liquor) (40% alcohol): 1.5 oz
 Mental Health Integration
Adult

CIDI based Bipolar Disorder Screening Scale

Read the questions below and answer:

1. Some people have periods lasting several days when they feel much more excited and full of energy than usual.
Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things
that are unusual for them, such as driving too fast or spending too much money.
a. Have you ever had a period like this lasting several days or longer? Yes No

2. Have you ever had a period lasting several days or longer when most of the time you were so irritable or grouchy
that you either stared arguments, shouted at people or hit people? Yes No

If you answer “No” to both question 1 and 2, you may skip the rest of the questions.

People who have episodes like this often have changes in their thinking and behavior at the same time. Like
being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in many
ways they would normally think inappropriate.

3. Did you ever have any of these changes during your episodes of being excited and full or energy or very irritable
or grouchy? Yes No

Think of an episode when you had the largest number of changes like these at the same time. During that episode,
which of the following changes did you experience?

Questions Yes No
4. Were you so irritable that you either started arguments, shouted at people, or
hit people?
5. Did you become so restless or fidgety that you paced up and down or couldn’t
stand still?
6. Did you do anything else that wasn’t usual for you—like talking about things you
would normally keep private, or acting in ways that you would usually find
embarrassing?
7. Did you try to do things that were impossible to do, like taking on large amounts
of work?
8. Did you constantly keep changing your plans or activities?
9. Did you find it hard to keep your mind on what you were doing?
10. Did your thoughts seem to jump from one thing to another or race through your
head so fast you couldn’t keep track of them?
11. Did you sleep far less than usual and still not get tired or sleepy?
12. Did you spend so much more money than usual that is caused you to have
financial trouble?