MH Questionnaire - eSignature


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Client Legal Name:   Preferred Name:  

Person Completing this form: DOB:

How do you identify your gender:   Pronouns:  

 

Parent/Legal Guardian Name (If under 18):

Are you a parent?
 
If yes, Child/Children names and ages:
 
Are you in a relationship right now?
 
Who do you live with right now?   
What/Who are the support system(s) in your life? (ex: family/friends/church/school/community group etc):  
What would you say are some of your strengths?  
How would you describe your cultural background and influences?  
How would you describe any spiritual or religious belief systems/practices?  
Are you currently in school?
       
If yes, where and what grade/program?
 
Are you currently working?
 
If yes, where and how long/how many hours/week?
 
How would you describe your physical health? (current/past conditions, medications etc):
 
How would you describe your family health history?
 
Please share any significant distressing or traumatic events happen in your life?     
Have you ever had any thoughts or attempts at harming yourself?
 
Any family history of substance abuse?
 
What substances have you used (How often/since what age):
 
Have you been in treatment for any substance use?
                       
If yes, when, and how was the experience?
 
CAGE-AID Chemical Health Assessment:
  • Have you ever felt that you ought to cut down on your drinking or drug use? 
     
  • Have people annoyed you by criticizing your drinking or drug use?
     
  • Have you ever felt bad or guilty about your drinking or drug use?
     
  • Have you ever had a drink or used drugs first thing in the morning (eye-opener) to steady your nerves, get rid of a hangover, or get the day started?     
     
 
 If you have had mental health services before, when and where was that?  
 
What is your main reason for seeking services right now?  
 
What life changes or stressful events have been going on lately?  
 
What days and times would you prefer to have counseling appointments?   
 
Do you receive other services with us? 
 

 

Please select any symptoms you have experienced in the past six months:

Leave this empty:

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Document name: MH Questionnaire - eSignature
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September 2, 2021 5:47 am CSTMH Questionnaire - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12