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Haven Treatment Center Mental Health Screening

Birthday
Month
Day
Year
1.Did you start any new medications or have a change in medications?
Yes
No
2.Do you feel that you live in a safe and healthy environment?
Yes
No
3.Do you feel supported by your family?
Yes
No
4.Do you feel threatened or bullied by peers?
Yes
No
5.Do you experience "ups" as well as "downs: with your mood?
Yes
No
6.Do you experience hyperactivity or inattention in your daily activities?
Yes
No
7.Do you lack interest in activities, hobbies, and what is happening around you?
Yes
No
8.Are you experiencing any type of psychosis, (hearing or seeing anything unusual that others can't)?
Yes
No
9.Do you at times feel that you are being watched or followed when there is no evidence of a threat?
Yes
No
10.Have you experienced any type of traumatic event that has been difficult to overcome?
Yes
No
11. Have you experienced any type of trauma within the last 24-72 hrs?
Yes
No
12. have you self-harmed within the last 24-72hrs
Yes
No
13. Do you at times wish you went to sleep and never wake up?
Yes
No
14. On a scale of 0 to 5, how down, depressed, or hopeless do you feel?
0
1
2
3
4
5-very depressed, hopeless, and down
15. On a scale of 0 to 3, how bad are your thoughts of suicide today?
0- no thoughts
1- some thoughts
2- desire to act on thoughts
3- plan and/or intent
16. On a scale of 0 to 5, how down, depressed, or hopeless do you feel?
0- Not at all anxious
1
2
3
4
5 - Very Anxious
18. Weight loss or gain of 10 lbs or more in the last 3 months
Yes
No
19. Any eating habits or behaviors that may indicate an eating disorder: bingeing, or induced vomiting?
Yes
No
20. Is this an increase or decrease in appetite?
Increase
Decrease
23. Are you having any sleep difficulties (falling/staying asleep/waking up)?
Yes
No
26. Within the last 72 hours, are you currently relying on alcohol and drugs as a coping mechanism?
Yes
No
27. Activities of Daily Living (ADLs). Do you experience any difficulty in your ability to perform the following activities?
Insurance-We accept Medicaid, Medicare , and Commercial Plans
Date
Month
Day
Year

I give Haven Treatment Center to provide a mental health screening and schedule a intake assessment. I understand minors under the age of 18 must have a parent / guardian approval prior to submitting. Upon submission a member from admissions will send a HIPPA secured link to complete a intake packet.


In the event of an emergency please call 911 or go ton the nearest emergency room

Physicians are on the medical staff of Haven Treatment Center, but, with limited exceptions, are independent practitioners who are not employees or agents of Haven Treatment Center. The facility shall not be liable for actions or treatments provided by physicians.  All physicians are contractors and bill for their services seperatley.

© 2025 HAVEN TREATMENT CENTER. ALL RIGHTS RESERVED.

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