Obsessive Compulsive Disorder Screening Form

SUMMIT BEHAVIORAL HEALTH

Obsessive-Compulsive Disorder (OCD) Screening Tool
This is a screening tool to help you determine whether you might have Obsessive-Compulsive Disorder (OCD) that needs professional attention. This screening tool is not designed to make a diagnosis of OCD but to be shared with Summit Behavioral Health mental health professional to inform further conversations about diagnosis and treatment. One of our providers will perform a free review of your form and contact you to discuss potential care options.
INSTRUCTIONS

1) Fill and submit shown form

2) Choose if you want Summit BHP to contact you to review of your results

3) Select date/time for a brief virtual meeting
Date *

Month Day Year
Date
QUESTIONNAIRE

Are you troubled by the following? *

	SELECTION
Do you have unwanted ideas, images, or impulses that seem silly, nasty, or horrible?
Do you worry excessively about dirt, germs, or chemicals?
Are you constantly worried that something bad will happen because you forgot something important, like locking the door or turning off appliances?
Do you experience shortness of breath?
Are you afraid you will act or speak aggressively when you really don't want to?
Are you always afraid you will lose something of importance?
Do you ever experience “jelly” legs?
Trouble falling or staying asleep, or restless and unsatisfying sleep
Are there things you feel you must do excessively or thoughts you must think repeatedly to feel comfortable or ease anxiety?
Do you wash yourself or things around you excessively?

Do you consent to Summit BHP contacting you about your results and care options? *
Select a date/time that works for you to discuss with Summit BHP staff:
Name

First Name Last Name
Age
Gender
Mobile Phone Number

Area Code Phone Number
Summit Behavioral Health

2115 County Road D East, Suite C-100, Maplewood, MN 55109

Ph: 651-358-7020 www.SummitBHP.com
Should be Empty:

QUESTIONNAIRE