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Mental Health Prescreening Form

This prescreening form is designed to provide an initial evaluation of your mental well-being. Based on your responses, it will intelligently guide you to more targeted assessments, offering a streamlined approach to understanding and addressing your unique mental health needs. Your well-being matters to us.

In the last three months, I have experienced a major or signigicant life event or change?

Yes No

Some of my concerns involve substance use (alcohol, marijuana, etc)?

Yes No

I have issues paying attention, sitting still, losing things, or getting through work/school?

Yes No

I have been feeling worried, scared or nervous, sometimes to the point of panic?

Yes No

My child is exhibiting symptoms of anxiety (separation, school, social, mutism, etc)?

Yes No

I am seeking treatment for issues related to behavior?

Yes No

Have you been experiencing up and down moods (e.g., times when you feel highly motivated followed by feeling down or depressed)?

Yes No

My child has difficulty with sleep, attention, irritability, and anger management, but also has periods where they are normal or extremely elevated?

Yes No

I (or my child) is extremely preoccupied with perceived flaws in appearance that seems to be minor. I/they feel ugly or deformed?

Yes No

My child lies, skips school, initiates fights with others, and has been known to steal things of value?

Yes No

I feel down or sad, almost every day, for the last two weeks or more?

Yes No

My child is usually irritable and has recurrent temper outbursts?

Yes No

I have issues related to eating (e.g., binging, not eating enough, distorted views of my body)?

Yes No

I feel like I have been born into the wrong body?

Yes No

My child has bouts of explosive anger, sometimes followed by periods of being down or sad?

Yes No

I have a problem related to stealing things?

Yes No

My child loses their temper a lot, argues with adults, and disobeys rules?

Yes No

I have general and/or specific physical pain?

Yes No

I have unusual sex related fetishes or fantasies?

Yes No

I struggle with making friends, keeping intimate partners, or enjoying social activities?

Yes No

I (or my child/family member) struggles with hallucinations (hearing or seeing things) or fears about being watched or followed?

Yes No

I get a lot of pleasure from watching things catch fire or burn?

Yes No

I struggle with sexual performance issues?

Yes No

I have been experiencing issues with sleep (e.g., falling asleep, staying asleep, waking up)?

Yes No

I have been exposed to violence or trauma (including childhood abuse, an accident, rape, or near death experience)?

Yes No

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