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Mental Health Screening

Please complete the following form as accurately as possible. All information is confidential and will be used to help determine the most appropriate level of care.


Required fields are marked with an asterisk (*).

Client Information
As the client's parent or legal guardian, is there a court order, custody agreement, or legal guardianship document that applies to this client?
Yes
No
Not Applicable

This includes any legal document that affects custody, guardianship, educational decision-making, or access to the client's records.


Examples include:

  • Custody order

  • Parenting plan

  • Guardianship order or letters of guardianship

  • Court order regarding custody or educational decision-making

Accepted file types: PDF, JPG, JPEG, or PNG.

Date of Birth
Month
Day
Year
Are you Hispanic or Latino?
Yes
No
Prefer not to answer
Race (Select all that apply.)
Mental Health Screening
1. Have you started any new medications or had any changes to your 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 or primary support system?
Yes
No
4. Do you currently feel threatened, intimidated, or bullied by others?
Yes
No
5. Do you experience significant changes in your mood, including periods of feeling unusually "up" as well as "down"?
Yes
No
6. Do you experience hyperactivity, difficulty paying attention, or problems with concentration during your daily activities?
Yes
No
7. Have you recently lost interest in activities, hobbies, or things you usually enjoy?
Yes
No
8. Are you currently hearing or seeing things that others do not (hallucinations)?
Yes
No
9. Do you ever feel that you are being watched or followed when others do not share that concern?
Yes
No
10. Have you experienced a traumatic event that has been difficult to cope with or overcome?
Yes
No
11. Have you experienced a traumatic event within the past 24-72 hours?
Yes
No
12. Have you engaged in self-harm within the past 24-72 hours?
Yes
No
13. Have you had thoughts that you would be better off not waking up or that you wish you could go to sleep and not wake up?
Yes
No
14. How down, depressed, or hopeless do you feel today?
0 – Not at all
1 – Slightly
2 – Mildly
3 – Moderately
4 – Very
5 – Extremely depressed, hopeless, or down
15. How severe are your thoughts of suicide today?
0 – No thoughts
1 – Some thoughts
2 – Strong desire to act on those thoughts
3 – Active plan and/or intent
16. Do you currently have a suicide plan or thoughts of harming another person?
Yes
No
17. Are you currently experiencing panic attacks?
Yes
No
19. Do you have any food allergies?
Yes
No
20. Have you lost or gained 10 pounds or more within the past three months?
Yes
No
21. Do you have any eating habits or behaviors that may indicate an eating disorder (such as binge eating, restricting food, or self-induced vomiting)?
Yes
No
22. Have you ever been diagnosed with anorexia, bulimia, or another eating disorder?
Yes
No
23. Do you have dental problems that interfere with eating?
Yes
No
24. Are you currently experiencing difficulty sleeping (falling asleep, staying asleep, or waking too early)?
Yes
No
27. Within the past 72 hours, have you used alcohol or drugs to cope?
Yes
No
28. Do you have difficulty performing any of the following activities? (Select all that apply.)
Insurance

We accept all insurance plans.

Authorization & Consent

By signing below, I authorize Haven Treatment Center to conduct a mental health screening and schedule an intake assessment. I understand that individuals under the age of 18 must have the consent of a parent or legal guardian before this form is submitted.


I understand that, upon submission of this form, a member of the Admissions Team will send me a HIPAA-secure link to complete the intake packet.


I understand that, during the course of my care, Haven Treatment Center may determine that additional services, evaluations, or specialized treatment outside of Haven Treatment Center would benefit my health, safety, or well-being.


I authorize Haven Treatment Center and its staff to make referrals to appropriate healthcare providers, agencies, or professionals when clinically indicated. Any referral will be made in accordance with applicable federal and state privacy laws protecting the confidentiality of my personal health information.


I understand that I have the right to ask questions about any recommended referral and may choose whether to pursue services with the recommended provider.


Emergency Notice

If you are experiencing a medical or psychiatric emergency, call 911 or go to the nearest emergency department immediately. If you are experiencing thoughts of suicide or are in emotional distress, call or text 988 to reach the Suicide & Crisis Lifeline.

Date
Month
Day
Year
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