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contact@ewingmentalhealthllc.com

Ewing Mental Health LLC

Screening Form

New Consumer Telephone Screening Form

CLIENT NAME
MM slash DD slash YYYY
ADDRESS
MM slash DD slash YYYY
INSURANCE PROVIDER
POLICY HOLDERS NAME
MM slash DD slash YYYY

2. ARE YOU IN CRISIS (REFER TO ER IF YES, NO APPOINTMENT)
3. ARE YOU CURRENTLY ON PSYCHIATRIC MEDICATIONS?
4. ARE YOU STABLE ON YOUR MEDICATIONS?
5. ARE YOU CURRENTLY SEEING A PSYCHIATRIST?
6. ARE YOU CURRENTLY SEEING A THERAPIST?
7. ANY INPATIENT/OUTPATIENT TREATMENT FOR MENTAL HEALTH OR SUBSTANCE ABUSE?
8. ANY HISTORY OF SUICIDE ATTEMPT?
9. DO YOU FEEL YOU ARE A HARM TO YOURSELF OR OTHERS
10. DO YOU EXPERIENCE ANY SYMPTOMS OF DEPRESSION, ANXIETY AND PANIC ATTACKS

REFERRAL SOURCE

NAME
ADDRESS