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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? YesNo

If yes, Child/Children names and ages:

Are you in a relationship right now? YesNo

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? YesNo

If yes, where and what grade/program?

Are you currently working?

YesNo

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?

YesNo

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?

YesNo

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? YesNo

Have people annoyed you by criticizing your drinking or drug use? YesNo

Have you ever felt bad or guilty about your drinking or drug use? YesNo

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? YesNo

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? ARMHS CTSS CSP Roots Other

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

Sadness/ tearfulness

Feeling down or depressed

Panic Attacks

Feelings of nervousness, tension or anxious

Worrying all the time

Racing thoughts

Skipping school/work

Staying out late

Sleeping too much

Sleeping too little

Trouble Falling Asleep

Trouble Staying Asleep

Acting out sexually

Being unhappy during or after sex

Trouble concentrating

Easily distracted

Poor attention

School Anxiety

Eating more often

Eating less often

Not feeling hungry

Under eating

Binge Eating

Making yourself vomit

Worried about weight: (too much weight or not enough)

Spending increased time alone

Social Anxiety

Self-Harming

Angry Often

Anger outbursts

Relationship stress with significant other/partner

Separation or divorce

Feeling Numb or Nothing

Feelings of loneliness

Low self-esteem/ low confidence

Getting into fights/arguing often

Loss of interest in previously enjoyed activities

Feeling or acting like a different person

Difficulty leaving your home

Mood swings

Repetitive behaviors (e.g. frequent checking, hand washing

Feeling hopeless and/ or helpless

Gender identity

Family problems

Trouble with Memory

Being tired during the day

Flashbacks

Hearing things that are not there

Sexual identity

Nightmares/ sleepwalk

Suicidal thoughts/ feelings

Thoughts or actual self-harm

Being abused

Seeing things that are not there

Issues with peers/friendships

Low Impulse Control

Finances

Being Bullied

Job/Work/Career Worries

Perfectionism

Making/keeping friends

Pregnancy

Parenting

Troubled about future plans

Thoughts about harming or killing someone else

Fire setting

Feelings of guilt

Unresolved grief/loss

Worried about a place to live

Religious/ spiritual concerns

Stealing

Other:

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Your email address

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September 2, 2021 5:47 am CDT

MH Questionnaire - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12