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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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Current Vocational/Employment
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Other Employment Status
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For Adolescent only
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During the past year have you
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Felt sad/lonely/hopeless
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Stopped enjoying things
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Wanted to eat more or less
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Had problems sleeping
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Doing what is needed at home
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Heard voice/ seen strange things
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Burned or cut self
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Prescribed medication for feelin
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Tried to kill yourself
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Thoughts about hurting/dying
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Trouble with law/school/parents
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Lost friends due to your drinks
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Used alcohol/ drugs
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Used alcohol/drugs more than
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Planned free time to drink/drugs
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Drink more alcohol to feel high
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Tried to stop drink/drug
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Experienced traumatic event
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Been afraid of parents
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Hit/slapped/kicked in a bad way
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For Adult
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During the past year
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Preoccupied with alcohol/drugs
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Problems caused by alcohol/drug
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Did you keep using alcohol/drugs
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Alcohol/drugs more than intended
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More drinks to get same effect
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Drink to alter the way you feel
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Tried stop drink/drug but couldn
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Experienced serious depression
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Thoughts of harming self
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At times thinking speeds up
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Attempted suicide
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Felt can't trust your family
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Medication for psychological
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Experienced hallucinations
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Ever been hit/slapped/kicked
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Been emotionally/sexually hurt
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Experienced a traumatic event
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Traumatic event repeated
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Traumatic event interfered life
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How often do you brush your teeth?
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