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MENTAL HEALTH SCREENING FORM
Mental Health Screening Form III
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Mental Health Screening Form III
Instructions:
In this program, we help people with
all
their problems, not just their addictions. This commitment includes helping people with emotional problems. Our staff is ready to help you to deal with any emotional problems you may have, but we can do this only if we are aware of the problems. Any information you provide to us on this form will be kept in strict confidence. It will not be released to any outside person or agency
without your permission
. If you do not know how to answer these questions, ask the staff member giving you this form for guidance. Please note, each item refers to your
entire life history
, not just your current situation, this is why each question begins –“Have you
ever
....”
1) Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an emotional problem?
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Yes
No
2) Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems?
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Yes
No
3) Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other emotional problem?
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Yes
No
4) Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?
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Yes
No
5) Have you ever heard voices no one else could hear or seen objects or things which others could not see?
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Yes
No
6a) Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself?
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Yes
No
6b) Did you ever attempt to kill yourself?
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Yes
No
7) Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot or stabbed?
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Yes
No
8) Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending social events, being in a crowd, being alone, being in places where it may be hard to escape or get help?
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Yes
No
9) Have you ever given in to an aggressive urge or impulse, on more than one occasion, that resulted in serious harm to others or led to the destruction of property?
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Yes
No
10) Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior?
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Yes
No
11) Have you ever experienced any emotional problems associated with your sexual interests, your sexual activities, or your choice of sexual partner?
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Yes
No
12) Was there ever a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting, engaging in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up?
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Yes
No
13) Have you ever had a period of time when you were so full of energy and your ideas came very rapidly, when you talked nearly non-stop, when you moved quickly from one activity to another, when you needed little sleep, and believed you could do almost anything?
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Yes
No
14) Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you would faint?
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Yes
No
15) Have you ever had a persistent, lasting thought or impulse to do something over and over that caused you considerable distress and interfered with normal routines, work, or your social relations? Examples would include repeatedly counting things, checking and rechecking on things you had done, washing and rewashing your hands, praying, or maintaining a very rigid schedule of daily activities from which you could not deviate.
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Yes
No
16) Have you ever lost considerable sums of money through gambling or had problems at work, in school, with your family and friends as a result of your gambling?
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Yes
No
17) Have you ever been told by teachers, guidance counselors, or others that you have a special learning problem?
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Yes
No
Are You Human? Answer This: 4+4=?
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