Healthcare Mental Health Questionnaire

Healthcare Mental Health Questionnaire

Please complete this questionnaire to the best of your ability. The information you provide will be used to assess current mental health needs, inform treatment planning, and assist with safety evaluation. If completing on behalf of another individual, indicate your legal relationship in the signature section. All responses are confidential except as required by law.

Patient Information

Date of Birth:    Gender:

Insurance / Billing (if applicable)

Presenting Concerns

When did these concerns begin?    Have symptoms been:

Current Symptoms (check all that apply)

Depressed mood or sadness Excessive worry or anxiety Sleep disturbance (insomnia/hypersomnia) Changes in appetite or weight Difficulty concentrating or memory problems Increased substance use Unexplained physical symptoms Mood swings/irritability None of the above

Mental Health & Medical History

Substance Use

Do you use tobacco, alcohol, or other substances?

Have you experienced problems as a result of substance use (legal, work, family)? Yes No

Risk Assessment

Have you had thoughts of harming yourself or suicide in the past year? Yes No

Have you had thoughts of harming others or violence in the past year? Yes No

Functional Impact & Treatment History

Legal / Safety Notices and Authorization

Confidentiality: Information provided is protected by law and will be kept confidential except where disclosure is permitted or required by law. Exceptions include: imminent risk of harm to self or others, suspected abuse or neglect of a child, elder, or dependent adult, court order, or when information is necessary for treatment coordination. By signing below, you acknowledge understanding of these limits to confidentiality.

Authorization to Treat and Release Information: By signing, the patient authorizes the treating clinician to provide mental health services as clinically indicated and to release or obtain relevant records to coordinate care with other health professionals, payers, or legal representatives as necessary for treatment, billing, or legal requirements. This authorization does not apply to psychotherapy notes except as specifically authorized in writing.

Revocation: This authorization may be revoked in writing at any time, except to the extent action has already been taken in reliance on the authorization. Revocation does not affect disclosures made prior to receipt of written revocation.

Expiration: This authorization will expire on:

Acknowledgment of Accuracy: I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge and that I have disclosed any relevant history that may affect my care.

HIPAA Privacy Practices: I acknowledge that I have been offered access to the practice's Notice of Privacy Practices describing how protected health information may be used and disclosed, and my rights with respect to that information. Acknowledged

Additional Consent Options

I consent to electronic communication (appointment reminders, treatment coordination). Yes No

I consent to the sharing of limited information for emergency contact purposes. Yes No

Sign Now