Pre-scheduling Questionnaire for Dr. Amanda Williams

If you have a mental health emergency: DO NOT complete this form, instead please call 911 or the 24/7 Georgia Crisis and Access line at 800-715-4225 (or text 741741).

You must be 18 or older and a resident of Georgia to schedule. If you do not live in the state of Georgia, YOU MAY NOT see Dr. Williams for treatment due to state medical licensing laws.

Name*

First NameLast Name

Age*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Briefly explain your presenting problem or question*

Over the past 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all	A few days	Several days	Nearly daily
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Sleeping more than usual
Sleeping less than usual
Tired/low energy
Appetite less than usual
Appetite more than usual
Difficulty concentrating
Forgetful
Irritable
Crying/felt like crying
Restless or agitated
Feeling nervous anxiety or on edge
Not able to stop or control worrying
Less interested in sex than usual
Feeling worthless
Thoughts that you would be better off dead or of hurting yourself

If answer to final question above is a few days, several days or nearly daily, please explain (type N/A if your answer was "Not at all"): *

For any answers other than "Not at all", how difficult have these problems made it for you to do your work, take care of things at home or get along with other people*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Have you ever attempted suicide?*

YesNo

Have you ever been psychiatrically hospitalized?*

YesNo

Are you actively meeting with a therapist or counselor*

YesNo

Please list ALL current medication with dosages. (None if on no medications.)*

Pre-scheduling questionnaire