Original One Page Screen
Name:________________________________________ Age ____ DOB ____________Date____________
Referred by:________________________School/Work:_____________________HighestGrade__________
List the three main problems you would like addressed in order of importance:
1._________________________________________________________________________________________________________
2._________________________________________________________________________________________________________
3.__________________________________________________________________________________________________________
GENERAL MENTAL HEALTH CHECK AND/OR CIRCLE WHAT YOU THINK APPLIES
( ) 1. Overly active, on the go, can’t sit still, and/or an inner sense of restlessness
( ) 2. Doesn’t pay attention, or can’t focus or concentrate on boring stuff
( ) 3. Doesn’t slow down stop and think before talking or doing
( ) 4. Short fuse, easily made angry, can’t calm self down within 20 min
( ) 5. Feeling sad, crying, saying and doing negative things, not normal self
( ) 6. Can’t control anger, breaking things, self mutilating, dangerous to others
( ) 7. Hurting self, talk of suicide, being better off dead, dangerous to self
( ) 8. Presently unpleasant,irritable, nasty, mean, colicky as infant, severe tantrums
( ) 9. Severe unusual separation anxiety, frequent school absences, headaches
( ) 10. Mood swings, ups and downs of feeling states, Dr Jekle & Mr. Hyde
( ) 11. Talks too much, too fast, not always logical, difficult to follow
( ) 12. Sleep difficulties, too much/little, wakes up, dreams seem real, nightmares
( ) 13. Excessive eating, especially in evening, waking up after asleep and eating
( ) 14. Overly suspicious, paranoid, thoughts seem like voices, odd, bizarre-strange
( ) 15. Too worried, afraid to do things, go places, shy, stage fright, panic attacks
( ) 16. Excessive eye blinking, facial movements, throat clearing, sniffing, snorting
( ) 17. Does things over & over, rituals, touching, counting, hand washing, ordering
( ) 18. Sensitivities to sound, touch, light, taste, smells, foods other things
( ) 19. Unaware of time, place, who you are, dazed, lost in time, confused, sleep like
( ) 20. Over use of drugs, alcohol, tobacco, exercise, food, TV, video games
( ) 21. Trouble reading, spelling, math, speech, co ordination difficulties
( ) 22. Witnessed domestic violence, victim of neglect, physical and/or sexual abuse
( ) 23. Poor or lack of use of language, facial expressions, gestures, to communicate
( ) 24. Poor emotional give and take like sharing affection, joy and other feelings
List all present medications:_______________________________________________________________________________
List Present Medical Problems:________________________________________________________________________________
List all past psychiatric medications:________________________________________________________________________________
List all bad drug reactions, side effects, food & drug allergies:________________________________________________________________________________
List All Psychiatric Medications Close And Distant Relatives Have Been
On_______________________________________________________________________________________
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