Symptoms and goals check-in

Symptoms and goals check-in
Name:*

First NameLast Name
Birth Date

MonthDayYear
Date
Please check the box next to the number that best describes your experience

Over the last 2 weeks, on how many days have

you been bothered by any of the following
Little interest or pleasure in doing things*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Feeling down, depressed, or hopeless*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Trouble falling or staying asleep*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Sleeping too much*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Poor appetite*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Over eating*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Trouble concentrating on things, such as reading the newspaper or watching television*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Moving or speaking so slowly that other people have noticed*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Being so fidgety or restless that you have been moving around a lot more than usual*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Thoughts that you would be better off dead or of hurting yourself in some way*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Cutting yourself, hurting yourself in some other way without the intent to kill yourself, or doing other risky things that may jeopardize your physical or mental well-being.*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Feeling nervous, anxious, or on edge*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Not being able to stop or control worrying*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Worrying too much about different things*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Trouble relaxing*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Being so restless it is hard to sit still*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Becoming easily annoyed or irritable*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Feeling afraid as if something awful might happen*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Having nightmares*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
Having strong emotional responses or outbursts*

0-Not at all1-Several Days2-More than half the days3-Nearly Every day
What progress do you feel you’ve made in therapy the past 6 months or since you began therapy with Mantra Mental Health?*
How are your mental health symptoms currently impacting you?*
Who else in your life do these issues impact?*
What are your goals for therapy for the next 6 months or so?*
Please list all psychiatric and non-psychiatric medications here. Include doses and frequencies.*
What side-effects do you experience from these medications?*
Has your insurance changed in the past 6 months or since you completed your new client paperwork? If so please provide name of insurance provider and plan ID number in space below. Type N/A or none if insurance hasn't changed*
Please provide your emergency contact's name and phone number in the space below (even if you have provided the same info in the past).*
Please provide your current address (even if you have provided the same info int the past)*
Please provide any other addresses where you may be when you join a telehealth session (write "none" if you plan to always meet at your home address)*
By signing below, you are verifying that you are the individual that completed this document. You also agree for Mantra Mental Health, LLC to bill any new insurances provided. You also agree that your therapist may contact your emergency contact in the case of an emergency.
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