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HOME
ABOUT
FEES
SERVICES
CONTACT
RESOURCES
FORMS
Adult Registration Intake Form
Child Registration Form
Patient Health Questionnaire Form (PHQ-9)
General Anxiety Disorder (GAD-7)
Adult ADHD Self-Report Scale Form
Couple’s Counseling Intake Form
Good Faith Estimate for Services
Release of Information Form
Tele Mental Health Informed Consent
Client Consent to Allow PHI by Email or Text Message
Patient Health Questionnaire Form (PHQ-9)
Please complete this form to the best of your ability.
Patient Health Questionnaire (PHQ-9)
Trinity Psych Wellness
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Please select your answers by clicking on the circle.
First Name
Last Name
Email
Today's Date
Date of Birth (Day/Month/year)
1. Little interest or pleasure in doing things.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
2. Feeling down, depressed, or hopeless.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
3. Trouble falling or staying asleep, or sleeping too much.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
4. Feeling tired or having little energy.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
5. Poor appetite or overeating.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
7. Trouble concentrating on things, such as reading the newspaper or watching television.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
8. Moving or speaking so slowly that other people could have noticed. Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
9. Thoughts that you would be better off dead, or of hurting yourself in some way.
Not at all
Several Days
More Than Half The Days
Nearly Every Day
If you checked off any problems above, indicate how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Click the button that applies.
Not difficult at all
Somewhat difficult
Very Difficult
Extremely difficult
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