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Clinical History
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Describe the current concern or problem that has brought you to TERRA
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What has led you to seek therapy for this (why now)?
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Have you already tried to resolve these concerns? What did you do and how did it work?
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Has anything else been helping to make things better?
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Have you received any mental health diagnoses from a professional?
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What are your goals for therapy?
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Describe any major stressful events or situations over the past year
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Please describe your relationship with others in your family (spouse, children, parents, siblings, etc)
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Please describe your relationship with peers, friends, and supports outside your home
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Current Concerns
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Patient is under 18
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Patient is 18 or older
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Please select all the items that pertain to you (1/3):
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Please select all the items that pertain to you (2/3):
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Please select all the items that pertain to you (3/3):
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Please select all the items that pertain to you (1/3):
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Please select all the items that pertain to you (2/3):
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Please select all the items that pertain to you (3/3):
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Mental Health History
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Have you ever received treatment from any mental health providers, including psychiatrists, therapists, or substance abuse counselors?
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Please provide the specialty of the provider, the name of the provider, the reason for treatment, and the approximate dates
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Have you ever experienced an event you would consider traumatic or abusive?
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Can you briefly identify what you have experienced?
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Have you ever been hospitalized or received inpatient/residential care for mental health concerns?
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Please provide the reason for this level of care, the name of the facility, and the approximate dates
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Please select any of the following that have been experienced by a member of your immediate family (parents, siblings, children)
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Medical History
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Do you currently have a medical provider?
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What is the name of your medical provider?
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Have you had any surgeries or non-psychiatric hospitalizations?
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Please describe and provide approximate dates
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Symptom Assessments
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This section is to be completed by the patient only. Select any applicable patient concerns
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depression / sadness / grief
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anxiety / worry
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sleep problems
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trauma / PTSD
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thoughts of suicide
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Other concerns (please list):
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PHQ-9 (Patient Health Questionnaire)
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Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select your answers.
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1. Little interest or pleasure in doing things.
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2. Feeling down, depressed, or hopeless.
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3. Trouble falling or staying asleep, or sleeping too much.
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4. Feeling tired or having little energy.
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5. Poor appetite or overeating.
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6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.
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7. Trouble concentrating on things, such as reading the newspaper or watching television.
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8. Moving or speaking slowly, or the opposite – being fidgety or restless.
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9. Thoughts that you would be better off dead, or of hurting yourself in some way.
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How difficult have these made it for you to take care of things or get along with other people?
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PHQ-9 Total Score (to be completed by clinician)
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GAD-7 (General Anxiety)
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Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select your answers.
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1. Feeling nervous, anxious, or on edge.
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2. Not being able to stop or control worrying.
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3. Worrying too much about different things.
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4. Trouble relaxing.
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5. Being so restless that it’s hard to sit still.
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6. Becoming easily annoyed or irritable.
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7. Feeling afraid as if something awful might happen.
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How difficult have these made it for you to take care of things or get along with other people?
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GAD-7 Total Score (to be completed by clinician)
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PCL-5 1-week (PTSD Checklist for DSM-5)
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Below are problems that can occur after stressful experiences. Keeping your worst event in mind, select how much you have been bothered by that problem IN THE PAST WEEK.
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Your worst event:
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1. Repeated, disturbing, and unwanted memories of the stressful experience?
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2. Repeated, disturbing dreams of the stressful experience?
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3. Feeling or acting as if the stressful experience were actually happening again, or reliving it?
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4. Feeling very upset when something reminded you of the stressful experience?
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5. Physical reactions when reminded of the stressful experience (heart pounding, trouble breathing, etc)?
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6. Avoiding memories, thoughts, or feelings related to the stressful experience?
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7. Avoiding external reminders (people, places, conversations, activities, objects, or situations)?
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8. Trouble remembering important parts of the stressful experience?
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9. Negative beliefs about yourself, other people, or the world ("I am bad," "the world is dangerous," etc)?
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10. Blaming yourself or someone else for the stressful experience or what happened after it?
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11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
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12. Loss of interest in activities that you used to enjoy?
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13. Feeling distant or cut off from other people?
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14. Trouble experiencing positive feelings (like being unable to feel happy, or love for people close to you)?
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15. Irritable behavior, angry outbursts, or acting aggressively?
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16. Taking too many risks or doing things that could cause you harm?
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17. Being “superalert” or watchful or on guard?
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18. Feeling jumpy or easily startled?
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19. Having difficulty concentrating?
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20. Trouble falling or staying asleep?
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PCL-5 Total Score (to be completed by clinician)
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Thank you for completing these assessments.
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Please disregard this question.
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Please disregard this question.
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