Arizona Psychiatry Request for Appointment

Language

English (US)

Request for Appointment
IMPORTANT

Please fill out this request for an appointment with as much information as possible.The submission process may take upwards of 30 minutes however this process will give us the appropriate information about whether or not we are able to meet your treatment needs. Incomplete forms will not be considered for appointments.

You will need to submit a photo of your insurance card on this form. Please take a photo of the front and back of your insurance card and have it saved on your computer or phone before starting this form. If we do not have a copy of this card we cannot verify benefits and no appointment will be offered.

WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP programs.

WE ARE NOT IN NETWORK WITH MOST MEDICARE ADVANTAGE PLANS

The only Healthcare Marketplace plan we are in network with is AmBetter.

We are Out of Network for all plans purchased on the Healthcare Marketplace other than AmBetter.

Please note that submission of this form does not guarantee an appointment nor does it constitute a patient-physician relationship.

We are unable to see anyone under the age of 17.

Appointments are scheduled on a case by case basis based on Appointment and Physician availability.

There is currently a wait list for new patients.
Are you currently experiencing a medical or psychiatric emergency (actively suicidal or immediate danger to self or others) that requires immediate attention?*

YesNo
Any and all life threatening emergencies need to be immediately evaluated at an emergency facility.

Do not continue this form and please immediately go to the nearest emergency room or dial 911.

Tucson Community Crisis Line:
If you are in immediate crisis, whether it be for you or your loved one, call the Community Wide Crisis line at (520) 622-6000 or 1 (866) 495-6735.

The National Suicide Prevention Lifeline is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. 1-800-273-TALK (8255).

Tucson Healthcare Facilities:

Banner University Medical Center – Emergency Room
1625 N Campbell Ave, Tucson, AZ 85724
(520) 694-0111

Banner University Medical Center (South Campus) – Emergency Room
2800 E Ajo Way, Tucson, AZ 85713
(520) 874-2000

Oro Valley Hospital Behavioral Health
1551 E Tangerine Rd, Oro Valley, AZ 85755
(520) 901-6250

Palo Verde Behavioral Health
2695 N Craycroft Rd, Tucson, AZ 85712
(520) 322-2888

Sonora Behavioral Health
6050 N Corona Rd, Tucson, AZ 85704
(520) 469-8700 or 1 (800) 349-0083

St. Joseph’s Hospital – Emergency Room
350 N Wilmot Rd, Tucson, AZ 85711
(520) 873-3884

St. Mary’s Hospital
1601 W St Mary’s Rd, Tucson, AZ 85745
(520) 872-4910

Veterans Affairs Medical Center – Veterans Only
3601 S 6th Ave, Tucson, AZ 85713
(520) 792-1450
I understand that submitting a request does not guarantee an appointment nor does it constitute a patient-physician relationship. New appointments are booked on a case by case basis, depending on physician availability, practice limitations, and ability to provide the appropriate level of treatment services.*

YesNo
I understand that any controlled medications (benzodiazepines, stimulants, opioids, hypnotics) previously prescribed by others does not guarantee continued prescriptions of those medications. Furthermore it is our practice wide policy to limit the use of controlled substances.*

YesNo
Do you have a guardian, a conservatorship, or has anyone been legally appointed to care for your medical or psychiatric needs?*

YesNo
Are you currently engaged in, or do you plan to become involved in, criminal or civil litigation?*

YesNo
Did a judge order you to obtain a psychiatric/psychological evaluation or is your appointment request due to the suggestion of an attorney or law firm?*

YesNo
Do you anticipate being involved in any form of legal proceedings?*

YesNo
Please understand that Arizona Psychiatry is a medical practice whose physicians specialize in the diagnosis and treatment of behavioral health disorders.

Medicolegal matters are often outside the scope of clinical medicine as they require expertise and communications to third parties, or may not involve both the diagnosis and treatment of a particular patient.

We will likely need to discuss your specific requests in more detail to determine how we can assist you, but in doing so we ask that you not disclose any confidential or legally privileged information.

Do not finish this form and please call our office for more information.
I understand that a credit card must be placed on file in order to schedule an intake appointment.*

YesNo
Is your request related to needing clearance or accommodations due to a mental health condition?*

YesNo
Please understand that Arizona Psychiatry is a medical practice whose physicians specialize in the diagnosis and treatment of behavioral health disorders. Our psychiatrists do not provide evaluations for work clearance, security clearance, generally suitability for work, suitability to own or posses a firearm, or approving return to work due to mental health issues.

You will need to speak specifically with a forensically trained mental health expert for this type of evaluation.

Name*

First NameMiddle NameLast Name
Gender*

MaleFemaleTransgender MaleTransgender FemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age (in years)
Date of Submission

MonthDayYear
Date
Email Address*
example@example.com
May we email you regarding treatment, scheduling, billing, prescriptions?*

YesNo
May we text message you regarding treatment, scheduling, billing, prescriptions?*

YesNo
I agree to receive notices and alerts related to treatment via text or SMS messaging to my mobile phone. I acknowledge that I may incur fees from my nmobile service provider for these messages and agree to pay any additional fees imposed by the mobile service provider for text or SMS messages.

Clear
Primary Phone Number*
Please enter a valid phone number.
May we text message you appointment reminders to this phone number?*

YesNo
May we leave a voicemail for you at this phone number?*

YesNo
Secondary Phone Number
Please enter a valid phone number.
Preferred Method of Contact*

Both Email and PhonePhoneEmailOther
Marital Status*

SingleIn RelationshipMarriedDomestic PartnershipDivorcedWidowed
Employment Status*

EmployedUnemployedDisabledRetiredStudentOther
Current Employer
Current University / College

PLEASE NOTE THAT WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP.

IF YOU DO NOT SEE YOUR INSURANCE LISTED PLEASE DO NOT FILL OUT THIS FORM AND CALL OUR OFFICE.
Primary Insurance*

AmBetterAetnaAetna Medicare AdvantageBlue Cross Blue ShieldBlue Cross Medicare AdvantageCIGNACIGNA Medicare AdvantageHumanaHumana Medicare AdvantageUnited HealthcareUnited Medicare AdvantageSelf PayOther
Self-Insurance election (e.g. "self-pay", "self-insured", "out-of-pocket", "cash-pay") requires notification of applicable laws and policies, as well as your explicit consent. While Arizona Psychiatry is an in-network provider with many health insurance companies, we do not currently have relationships with Medicare/Medicaid (AHCCCS) and some other select private insurers. In these instances, someone may elect to be self-insured (or pay "out-of-pocket") when either they do not have health insurance coverage, when the healthcare provider or practice is "out-of-network", or when patients explicitly do not want their insurance billed - instead electing to pay out of pocket at the time of service. Generally, someone who has health insurance coverage is obligated to submit healthcare claims to the insurer for reimbursement. If you otherwise have insurance or other types of health coverage, services received as "self-insured" will not likely be reimbursed by your insurance carrier or applied to your deductible, and may complicate your relationship with your health insurance company. You may want to discuss this and any repercussions with your insurance carrier before pursuing this option. By signing below, you are simply acknowledging that you have read this notification. We will speak with you in more detail about it later and clarify any questions you may have.
Signature

Clear
Insurance Subscriber Member ID*
Insurance Subscriber Group Number*
Insurance Customer Service/Claims/Eligibility Phone Number *
Insurance Subscriber Name*

First NameLast Name
Insurance Subscriber Date of Birth*

MonthDayYear
Date
Is the insurance subscriber address the same as the home address?

YesNo
Insurance Subscribers Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Insurance Subscriber*

SelfSpouseChildDomestic PartnerOther
Do you have a Secondary Insurance Plan?

YesNo
Secondary Insurance

AmBetterAetnaBlue Cross Blue ShieldCIGNAHumanaUnited HealthcareSelf PayOther
Secondary Subscriber Member ID
Secondary Subscriber Group Number
Secondary Insurance Customer Service/Claims/Eligibility Phone Number
Secondary Insurance Subscriber Name

First NameLast Name
Secondary Insurance Subscriber Date of Birth

MonthDayYear
Date
Secondary Insurance Subscribers Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Secondary Insurance Subscriber

SelfSpouseChildDomestic PartnerOther
Primary Insurance File Upload (Front and Back)

Cancelof
Secondary Insurance File Upload (Front and Back)

Cancelof

How were you referred to us?*

FamilyFriendInsurance WebsiteInternet SearchPrimary CarePsychologistTherapist / CounselorHospitalUniversity of Arizona CAPSOther
Who is your family member?
Who is your Primary Care provider?
Who is your psychologist?
Who is your therapist/counselor?
Do you have a preference of which psychiatrist you want to see?*

First AvailableDr. ChauhanDr. DowlingDr. FauqDr. Hadeed
Are you open to seeing the psychiatrist through a HIPAA compliant video telemedicine platform (Zoom)?*

YesNoUnsure
Are you currently on leave from work or school?*

YesNo
Are you currently on FMLA (Family and Medical Leave Act) or planning to use FMLA?*

YesNo
Are you currently on disability for any mental health or substance use related condition?*

YesNo
Are you considering applying for short term disability?*

YesNo
Have you ever been on short term disability or long term disability for psychiatric reasons?*

YesNo
Do you currently have an emotional service animal?*

YesNo
Are you seeking out accommodations or a letter for an emotional service animal?*

YesNo

Why are you seeking treatment?*

Attention and/or Concentration DifficultiesAnxietyDepressionMood SwingsSuicidal ThinkingPanic AttacksInsomniaDrug UseAlcohol UseHallucinationsDelusionsConfusion/Memory LossObsessionsCompulsionsTraumaNightmares / FlashbacksImpulsive BehaviorsRelationship DifficultiesProblems at WorkSecond OpinionSwitching Behavioral Health ProfessionalsOther
Please describe in detail the reasons why you are seeking treatment:*
Please provide specific information, concerns, symptoms that are relevant to this request.
What your the ideal appointment length? (does not guarantee appointment length)*

15 minutes or under15-30 minutes30-45 minutes45-60 minutes60 minutes or moreOther
Are you willing to take medications to address any mental health conditions?*

YesNoUnsure
Are you willing to engage in lifestyle changes to improve symptoms? (ex: diet, exercise, meditation)*

YesNoUnsure
Do you currently see a psychiatrist or mental health nurse practitioner?*

YesNo
What is the name of your current psychiatrist or mental health nurse practitioner?
Do you currently see a therapist or counselor?*

YesNo
What is the name of your therapist/counselor? What is their phone number?
Would you be willing to pursue therapy/counseling if it was recommended?*

YesNo
Do you have any complicated, potentially serious, or serious medical issues? If so please list them below.*
Do you have any drug allergies?
Have you received 2 or more COVID-19 vaccinations?

YesNo
Do you have a medical illness that prevents you from getting the COVID-19 vaccination?

YesNo
Have you recovered from a documented COVID-19 infection in the last 3 months?

YesNo
Please check any conditions that you currently have or have previously had*

NoneAdrenal tumor / massAdrenal insufficiencyAnemiaAngina / Chest PainArrhythmia / Irregular HeartbeatArthritisAutoimmune DiseaseBlood ClotsHigh Blood PressureLow Blood PressureCancerChronic Fatigue SyndromeChronic Lyme DiseaseChronic PainConcussions or Head InjuryCongestive Heart FailureCoronary Artery DiseaseType 1 DiabetesType 2 DiabetesEpilepsy / SeizuresEhlers Danlos SyndromeFaintingFibromyalgiaGallstones or Gallbladder DiseaseGastroesophageal Reflux Disease (GERD)GlaucomaGoutHeart AttackHeart DiseaseHemophilia or Other Bleeding DisorderHepatitisHigh CholesterolIrritable Bowel SyndromeKidney DiseaseKidney StonesLiver DiseaseLung DiseaseLymphatic DiseaseMigrainesMultiple Chemical SensitivityNeurological Disorder / DeficitParkinson DiseasePituitary Tumor or MassPostural Tachycardia SyndromeSleep ApneaStroke or Cerebral Vascular AccidentGI or Gastric/Stomach DiseaseHypothyroidismHyperthyroidismOther
Please list any non psychiatric medications you are currently taking*
Have you had any type of lab work/blood work done in the last 6 months?*

YesNo
What type of lab work/blood work was done? Who ordered it?
Have you ever been diagnosed with the following conditions:*

NoneADD/ADHDAnxiety DisorderAutismGeneralized Anxiety DisorderBipolar DisorderDepressive DisorderMajor Depressive DisorderPanic DisorderEating DisorderPersonality DisorderSplit Personality DisorderImpulse Control DisorderInsomniaNeurodevelopmental DisorderObsessive Compulsive DisorderPost Traumatic Stress DisorderSchizoaffective DisorderSchizophreniaPsychosisAlcohol AbuseDrug AbuseOther
Are you currently taking any psychotropic or psychiatric medication?*

YesNo
What psychiatric medications are you currently taking? What dose and frequency?
please include dose and frequency
Have you ever taken psychotropic or psychiatric medication?*

YesNo
What medications have you taken in the past?

Acamprosate (Campral)Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Asenapine (Saphris)Atomoxetine (Strattera)Brexpiprazole (Rexulti)Buprenorphine/Naloxone (Suboxone)Bupropion (Wellbutrin)Buspirone (Buspar)Carbamazepine (Tegretol)Cariprazine (Vraylar)Citalopram (Celexa)Clomipramine (Anafranil)Clonazepam (Klonopin)Clonidine (Catapres)Clozapine (Clozaril)Dextroamphetamine (Dexedrine)Dexvenlafaxine (Pristiq)Deutetrabenazine (Austedo)Diazepam (Valium)Disulfiram (Antabuse)Donepezil (Aricept)Doxepin (Silenor)Doxazosin (Cardura)Duloxetine (Cymbalta)Escitalopram (Lexapro)Esketamine (Spravato)Eszopiclone (Lunesta)Fluoxetine (Prozac)Fluphenazine (Prolixin)Fluvoxamine (Luvox)Gabapentin (Neurontin)Galantamine (Razadyne)Guanfacine (Intuniv)Haloperidol (Haldol)Hydroxyzine (Vistaril)Iloperidone (Fanapt)Imipramine (Tofranil)Lamotrigine (Lamictal)Levomilnacipran (Fetzima)Levothyroxine (Synthroid)Lisdexamfetamine (Vyvanse)Lithium (Lithobid)Liothyronine (Cytomel)Lorazepam (Ativan)Loxapine (Oxilapine)Lurasidone (Latuda)Memantine (Namenda)Methadone (Dolophine)Methylphenidate (Ritalin)Metformin (Glucophage)Mirtazapine (Remeron)Naloxone (Narcan)Naltrexone (Revia)Nefazodone (Serzone)Nortriptyline (Pamelor)Olanzapine (Zyprexa)Oxcarbazepine (Trileptal)Paliperidone (Invega)Paroxetine (Paxil)Prazosin (Minipress)Propranolol (Inderal)Phenelzine (Nardil)Quetiapine (Seroquel)Ramelteon (Rozerem)Risperidone (Risperdal)Rivastigmine (Exelon)Sertraline (Zoloft)Suvorexant (Belsomra)Topiramate (Topamax)Tranylcypromine (Parnate)Trazodone (Desyrel)Valbenazine (Ingrezza)Valpropate (Depakote)Varenicline (Chantix)Venlafaxine (Effexor)Vilazodone (Viibryd)VivitrolVortioxetine (Trintellix)Zaleplon (Sonata)Ziprasidone (Geodon)Zolpidem (Ambien)Other
Have you ever been admitted to a psychiatric facility?*

YesNo
What was the date of your last psychiatric admission? Where were you admitted?
How many times have you been admitted to a psychiatric facility?

1 time2 times3 times4 or more times
Have you ever been suicidal?*

YesNo
Have you ever attempted suicide?*

YesNo
How many times have you attempted suicide?

1 time2 times3 times4 or more times
What was the date of your last suicide attempt ? What method did you use?
Have you ever been to drug or alcohol detox?*

YesNo
How many times have you been to drug or alcohol detox?

1 time2 times3 times4 or more times

PHQ9
Have you ever experienced a significant period of depression?*

YesNo
Have you ever felt down, depressed, or sad for an extended period of time?*

YesNo
Are you currently feeling depressed, or sad more days than not?*

YesNo
Have things ever been so bad that you thought a lot about death or that you would be better off dead?*

YesNo
Have you ever thought about taking your own life?*

YesNo
Have you thought about taking your own life in the last month?*

YesNo
Have you seriously considered ending your life in the last week?*

YesNo

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

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
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
9. Thoughts that you would be better off dead, or of hurting yourself

PHQ9 Score

Severity Measure for Panic Disorder
Have you ever had multiple instances of an intense rush of anxiety, or what someone might call a “panic attack,” when you suddenly felt very frightened or anxious or suddenly developed a lot of physical symptoms?*

YesNo
Panic attacks are sudden outbursts of anxiety that develop suddenly and increase in intensity within about 10 minutes.
During the last 6 months, have you had a panic attack or a sudden rush of intense fear or anxiety?*

YesNo
Was at least 1 panic attack unexpected, as if it came out of the blue?*

YesNo
Did it happen more than once?*

YesNo
Approximately how many panic attacks have you had in your lifetime?*
Have you ever worried a lot (for at least 1 month) about having another panic attack?*

YesNo
Did you ever change your behavior or do something different (for at least 1 month) because of the attacks?*

YesNo

Think back to your most severe panic attack. Did you experience any of the following symptoms?*

	Yes	No
Shortness of breath or smothering sensations?
Feeling dizzy, unsteady, lightheaded, or faint?
Palpitations, pounding heart, or rapid heart rate?
Trembling or shaking?
Sweating?
Feelings of choking?
Nausea or abdominal distress?
Numbness or tingling sensations?
Flushes (hot flashes) or chills?
Chest pain or discomfort?
Fear of dying?
Fear of going crazy or doing something uncontrolled?

How distressing do you find these symptoms?*

No distressMild distressModerate distressSevere distressVery severe distress
PDS Score

Severity Measure for Social Anxiety Disorder
Does being in social situations or being around other people cause you significant distress?*

YesNo

Please answer the questions regarding your interactions and social situations over the past two weeks*

	Never	Occasionally	Half of the time	Most of the time	All of the time
felt moments of sudden terror, fear,or fright in social situations
felt anxious, worried, or nervous about social situations
had thoughts of being rejected, humiliated, embarrassed, ridiculed,or offending others
felt a racing heart, sweaty, trouble breathing, faint, or shaky in social situations
felt tense muscles, felt on edge or restless, or had trouble relaxing in social situations
avoided, or did not approach or enter,social situations
left social situations early or participated only minimally (e.g., said little, avoided eye contact)
spent a lot of time preparing what to say or how to act in social situations
distracted myself to avoid thinking about social situations
needed help to cope with social situations (e.g., alcohol or medications, superstitious objects

SAM Score

GAD-7
Over the past 6 months have you been feeling anxious and worried for a lot of the time?*

YesNo
Do you have the tendency to worry about things more than normal? OR do people ever tell you that you worry too much?*

YesNo

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

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worry
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

GAD7 Score

PCL-C
Have you ever experienced or been a victim of a life-threatening or traumatic event (including sexual assault or abuse) that caused intense fear, helplessness, or horror?*

YesNo

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please reach each carefully and pick the answer that indicates how much you have been bothered by that problem. If this event happened a long time ago, think back to when you felt most stressed about the life experience to answer.*

	Not at all	A little bit	Moderately	Quite a bit	Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Repeated, disturbing dreams of a stressful experience from the past?
Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?
Feeling very upset when something reminded you of a stressful experience from the past?
Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?
Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?
Avoid activities or situations because they remind you of a stressful experience from the past?
Trouble remembering important parts of a stressful experience from the past?
Loss of interest in things that you used to enjoy?
Feeling distant or cut off from other people?
Feeling emotionally numb or being unable to have loving feelings for those close to you?
Feeling as if your future will somehow be cut short?
Trouble falling or staying asleep?
Feeling irritable or having angry outbursts?
Having difficulty concentrating?
Being “super alert” or watchful on guard?
Feeling jumpy or easily startled?

PCL-C Score

MDQ
Has there ever been a period of time lasting around 1 week or longer where you were feeling so good, “high,” excited, or “on top of the world” that other people thought you were not your normal self?*

YesNo
Has there ever been a period of time lasting 1 week or longer where you were feeling unusually irritable, angry, or short tempered for most of the day, for at least several days?*

YesNo
Has there ever been a time lasting 1 week or longer where where you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?*

YesNo
Has there ever been a period of time lasting around than 1 week or longer where you slept much less but still felt rested?*

YesNo

Has there ever been a period of time when you were not your usual self and ...*

	Yes	No
Has there ever been a period of time when you were not your usual self and you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
Has there ever been a period of time when you were not your usual self and you were so irritable that you shouted at people or started fights or arguments?
Has there ever been a period of time when you were not your usual self and you felt much more self-confident than usual?
Has there ever been a period of time when you were not your usual self and you got much less sleep than usual and found you didn’t really miss it?
Has there ever been a period of time when you were not your usual self and you were much more talkative or spoke faster than usual?
Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down?
Has there ever been a period of time when you were not your usual self and you were so easily distracted by things around you that you had trouble concentrating or staying on track?
Has there ever been a period of time when you were not your usual self and you had much more energy than usual?
Has there ever been a period of time when you were not your usual self and you were much more active or did many more things than usual?
Has there ever been a period of time when you were not your usual self and you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
Has there ever been a period of time when you were not your usual self and you were much more interested in sex than usual?
Has there ever been a period of time when you were not your usual self and you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
Has there ever been a period of time when you were not your usual self and spending money got you or your family in trouble?
if you checked YES to more than one of the above, have several of these ever happened during the same period of time?
Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Please rate the severity of the following question*

	Not a problem	Minor problem	Moderate problem	Serious problem
How much of a problem did any of these symptoms cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights?

MDQ Score

YBOCS
Do you have any unusual or repetitive thoughts that you know are silly but you simply cannot stop thinking about (for example, being contaminated by germs)?*

YesNo
Do you feel there are certain rituals you have to do, such as cleaning, tap your hand a certain way or do things in sets of threes, which takes up a lot of time in the day?*

YesNo
Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing important things.

Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often they do repetitive, purposeful, intentional behaviors called rituals. The behavior itself may seem appropriate but it becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your breath.

Please answer each question by selecting the appropriate answer.
How much of your time is occupied by obsessive thoughts?*

NoneLess than 1 hr/day or occasional occurrence1 to 3 hrs/day or frequentGreater than 3 and up to 8 hrs/day or very frequent occurrenceGreater than 8 hrs/day or nearly constant occurrence
How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of them?*

NoneSlight interference with social or other activities, but overall performance not impairedDefinite interference with social or occupational performance, but still manageableCauses substantial impairment in social or occupational performanceIncapacitating
How much distress do your obsessive thoughts cause you?*

NoneNot too disturbingDisturbing, but still manageableVery disturbingNear constant and disabling distress
How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind?*

Try to resist all the timeTry to resist most of the timeMake some effort to resistYield to all obsessions without attempting to control them, but with some reluctanceCompletely and willingly yield to all obsessions
How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting your obsessive thinking? Can you dismiss them?*

Complete controlUsually able to stop or divert obsessions with some effort and concentrationSometimes able to stop or divert obsessionsRarely successful in stopping or dismissing obsessions, can only divert attention with difficultyObsessions are completely involuntary, rarely able to even momentarily alter obsessive thinking
How much time do you spend performing compulsive behaviors? How much longer than most people does it take to complete routine activities because of your rituals? How frequently do you do rituals?*

NoneLess than 1 hr/day or occasional performance of compulsive behaviorsFrom 1 to 3 hrs/day, or frequent performance of compulsive behaviorsMore than 3 and up to 8 hrs/day, or very frequent performance of compulsive behaviorsMore than 8 hrs/day, or near constant performance of compulsive behaviors (too numerous to count)
How much do your compulsive behaviors interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of the compulsions?*

NoneSlight interference with social or other activities, but overall performance not impairedDefinite interference with social or occupational performance, but still manageableCauses substantial impairment in social or occupational performanceIncapacitating
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?*

NoneOnly slightly anxious if compulsions preventedAnxiety would mount but remain manageable if compulsions preventedProminent and very disturbing increase in anxiety if compulsions interruptedIncapacitating anxiety from any intervention aimed at modifying activity
How much of an effort do you make to resist the compulsions?*

Always try to resistTry to resist most of the timeMake some effort to resistYield to almost all compulsions without attempting to control them, but with some reluctanceCompletely and willingly yield to all compulsions
How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions?*

Complete controlPressure to perform the behavior but usually able to exercise voluntary control over itStrong pressure to perform behavior, can control it only with difficultyVery strong drive to perform behavior, must be carried to completion, can only delay with difficultyDrive to perform behavior experienced as completely involuntary and over- powering, rarely able to even momentarily delay activity
YBOCS Score

BPD
Do you find that you can be feeling okay then suddenly feel angry, or you can be feeling okay and suddenly feel sad?*

YesNo
Do you think that the usual way that you react to things or behave with people has impacted your close relationships in a negative way?*

YesNo
Do you often have difficulty perceiving and interpreting yourself, other people, and/or events?*

YesNo
Do you get emotional easily, often for very little reason?*

YesNo

Please answer how you agree with each of the following statements:*

	Strongly disagree	Disagree	Neutral	Agree	Strongly Agree
I nearly always feel "empty."
I find that I often do one or more of the following: drive recklessly, engage in unsafe sex, abuse alcohol or drugs, binge eat, gamble or spend money recklessly.
Sometimes when I'm stressed out - especially if someone has abandoned me - I can get very paranoid, feel myself "spacing out" or dissociate.
I often idealize others, especially when I first meet them, and feel comfortable in sharing the most intimate details with them. But I often feel that these same people don't care enough and aren't there enough for me.
I'm sometimes very angry, extremely sarcastic and bitter, and feel like I have a hard time controlling this anger.
I've engaged in self-mutilating, self-harm, or suicidal behaviors, gestures or threats.
I often experience a sudden shift in the way I look at myself and my life, and completely change my goals, values and career focus.
I'm often afraid that others will abandon or leave me - so I'll make frantic efforts to avoid this abandonment (even when it's not real).
My mood can shift between extreme periods of anxiety, depression or irritability in just a few hours or days.
My views of others - especially those I care about - can shift dramatically and without any warning.
I would say most of my romantic relationships have been very intense - but not very stable.
I'm currently experiencing enough problems in this area of my life that it's negatively impacting my ability to go to school, work, be with friends or family, or have a romantic relationship.

BPD Score

NCI
Do you think that people are often jealous of your accomplishments or talents?*

YesNo
Do you find it easy to get people to do what you want?*

YesNo
Do other people ever tell you that you are irresponsible or impulsive?*

YesNo

Please answer whether or not you agree with the following statements*

	Yes	No
I really like to be the center of attention
I am no better or no worse than most people
Everybody likes to hear my stories
I always know what I am doing
I am more capable than other people
I expect a great deal from other people
I know that I am good because everybody keeps telling me so
I have a natural talent for influencing people
When people compliment me I sometimes get embarrassed
I insist on getting the respect that is due to me
I can read people like a book
I prefer to be a leader

NCI Score

Prodromal Questionnaire - 16
Have you had any strange or odd experiences lately that you cannot explain?*

YesNo
Do you ever hear things that other people cannot hear, such as noises, or the voices of other people whispering or talking?*

YesNo
Do you ever have visions or see things that other people cannot see?*

YesNo
Do you ever feel that people are bothering you or trying to harm you?*

YesNo
Has it ever seemed like people were talking about you or taking special notice of you?*

YesNo
Have you ever been diagnosed with psychosis?*

YesNo

Please indicate whether or not you agree with the following statements*

	True	False
I feel uninterested in the things I used to enjoy.
I often seem to live through events exactly as they happened before (déjà vu).
I sometimes smell or taste things that other people can’t smell or taste.
I often hear unusual sounds like banging, clicking, hissing, clapping or ringing in my ears.
I have been confused at times whether something I experienced was real or imaginary.
When I look at a person, or look at myself in a mirror, I have seen the face change right before my eyes.
I get extremely anxious when meeting people for the first time.
I have seen things that other people apparently can't see.
My thoughts are sometimes so strong that I can almost hear them.
I sometimes see special meanings in advertisements, shop windows, or in the way things are arranged around me.
Sometimes I have felt that I’m not in control of my own ideas or thoughts.
Sometimes I feel suddenly distracted by distant sounds that I am not normally aware of.
I have heard things other people can't hear like voices of people whispering or talking.
I often feel that others have it in for me.
I have had the sense that some person or force is around me, even though I could not see anyone.
I feel that parts of my body have changed in some way, or that parts of my body are working differently than before.

PQ 16 Score

Disordered Eating Measure
Have you ever regularly restricted food due to a fear of gaining weight?*

YesNo
Have you ever regularly purged food due to a fear of gaining weight?*

YesNo
Do you regularly eat excessively to the point you felt you had no control over eating?*

YesNo
How much more or less do you feel you worry about your weight and body shape than other people your age?*

I worry a lot less than other peopleI worry a little less than other peopleI worry about the same as other peopleI worry a little more than other peopleI worry a lot more than other people
How afraid are you of gaining 3 pounds?*

Not afraid of gainingSlightly afraid of gainingModerately afraid of gainingVery afraid of gainingTerrified of gaining
Compared to other things in your life, how important is your weight to you?*

My weight is not important compared to other things in my lifeMy weight is a little more important than some other things in my lifeMy weight is more important than most, but not all, things in my lifeMy weight is the most important thing in my life
Do you ever feel fat?*

NeverRarelySometimesOftenAlways
In the past 3 months, how many times have you had a sense of loss of control AND you also ate what most people would regard as an unusually large amount of food at one time, defined as definitely more than most people would eat under similar circumstances ?*
During these episodes of eating an unusually large amount of food with a sense of loss of control, do you:*

Eat much more rapidly than normal?Eat until feeling uncomfortably full?Eat large amounts of food when not feeling physically hungry?Eat alone because of feeling embarrassed by how much you are eating?Feel disgusted, depressed, or very guilty afterward?None
How distressed or upset have you felt about these episodes?*

Not at allA littleModeratelyGreatlyExtremely
In the past 3 months, how many times have you made yourself throw up?*
In the past 3 months, how many times have you used diuretics or laxatives?*
In the past 3 months, how many times have you exercised excessively?*
In the past 3 months, how many times have you fasted (intentionally not eaten anything for at least 24 hours in an attempt to prevent weight gain)?*
Do you consume a small amount of food (i.e., less than 1200 calories/day) on a regular basis to influence your shape or weight?*

YesNo
When was the last time you went on a diet?*

I have never been on a dietI was on a diet about one year agoI was on a diet about 6 months agoI was on a diet about 3 months agoI was on a diet about 1 month agoI was on a diet less than 1 month agoI'm on a diet now
Are you currently in treatment for an eating disorder?*

YesNoNot currently, but I have been in the past
DEM Score

Drug Abuse Screening Tool
Have you ever regularly used an illicit drug (cocaine, heroin, methamphetamine, psychedelics, etc) or used a prescription medication for non-medical reasons?*

YesNo
Are you currently using illicit drugs (cocaine, heroin, methamphetamine, psychedelics, etc) or prescription medications for non-medical reasons?*

YesNo
Please check the substances that you have used before*

CocaineHeroinInhalantsKetamineKratomLSDMarijuana/CannabisMDMAMethamphetaminePCPPrescription Opioids (Oxycodone, Oxycontin)FentanylPrescription Stimulants (adderall, ritalin, vyvanse)Prescription Benzodiazepines (xanax, ativan, valium)Other
Have you used drugs other than those required for medical reasons?*

YesNo
Do you abuse more than one drug at a time?*

YesNo
Are you always able to stop using drugs when you want to?*

YesNo
Have you had "blackouts" or "flashbacks" as a result of drug use?*

YesNo
Do you ever feel bad or guilty about your drug use?*

YesNo
Does anyone important in your life ever complain about your involvement with drugs?*

YesNo
Have you neglected your family because of your use of drugs?*

YesNo
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?*

YesNo
Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?*

YesNo
DAST Score

Alcohol Use Disorders Identification Test
Have you ever felt that you needed to cut down on drinking alcohol? OR Have you ever felt guilt about your drinking habits?*

YesNo
How often do you have a drink containing alcohol?*

NeverMonthly or less2 to 4 times a month2 to 3 times a week4 or more times a week
How many standard drinks containing alcohol do you have on a typical day when drinking? (12 oz beer, 1.5 oz hard liquor, 5 oz wine)*

1 or 23 or 45 or 67 to 910 or more
How often do you have six or more drinks on one occasion?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
During the past year, how often have you found that you were not able to stop drinking once you had started?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
During the past year, how often have you failed to do what was normally expected of you because of drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
During the past year, how often have you had a feeling of guilt or remorse after drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
During the past year, how often have you been unable to remember what happened the night before because you had been drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Have you or someone else been injured as a result of your drinking?*

NoYes, but not in the past yearYes, during the past year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?*

NoYes, but not in the past yearYes, during the past year
AUDIT Score

ASRS
Since childhood, is it normal for you to be easily distracted or disorganized?*

YesNo
Since childhood, is it normal for you to often miss important details or made mistakes at work (or school) or while taking care of things at home?*

YesNo
Since childhood, have you often started things and then dropped them without finishing because you lost your focus or got sidetracked?*

YesNo

Please mark the response that most closely represents the frequency of occurrence of each of the symptoms over the past 6 months.*

	Never	Rarely	Sometimes	Often	Very Often
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you find yourself talking too much when you are in social situations?
When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?

ASRS Score

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PHQ9 Calculation
PHQ9 Interpretation
MDQ Calculation
MDQ Interpretation
GAD7 Calculation
GAD7 Interpretation
SAM Calculation
SAM Interpretation
ASRS Calculation
ASRS Interpretation
PDS Calculation
PDS Interpretation
YBOCS Calculation
YBOCS Interpretation
PCL-C Calculation
PCL-C Interpretation
AUDIT Calculation
AUDIT Interpretation
DAST Calculation
DAST Interpretation
PQ 16 Calculation
PQ 16 Interpretation
BPD Calculation
BPD Interpretation
NCI Calculation
NCI Interpretation
DEM Calculation
DEM Interpretation
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PHQ9

Severity Measure for Panic Disorder

Severity Measure for Social Anxiety Disorder

GAD-7

PCL-C

MDQ

YBOCS

BPD

NCI

Prodromal Questionnaire - 16

Disordered Eating Measure

Drug Abuse Screening Tool

Alcohol Use Disorders Identification Test

ASRS

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