Screening Forms

Mental Health Screening Form

Name: ___________________________________________ Date: _______________________

1. Do you have any history of treatment from mental health professionals due to emotional or
behavior problems? ____No ____Yes
If yes, please answer a & b.
a. Are you currently seeing a mental health professional? ____No ____Yes
b. How many years total have you received mental health services? ____________
2. Have you ever been hospitalized for mental health reasons? ____No ____Yes
Date(s): ________________
For what purpose(s): _____________________________________________
3. Do you have any history of taking medications for mental health? ____No ____Yes
4. Check any of the following symptoms that are concerns for you.
____Anxiety ____Aggression ____Concentration
____Crying spells ____Depression ____Fatigue
____Fears ____Hallucinations ____High energy
____Hopelessness ____Hyperactivity ____Impulsive behaviors
____Irritability ____Intrusive thoughts ____Lack of pleasure
____Low motivation ____Nightmares ____Obsessive thoughts
____Panic attacks ____Restlessness ____Substance abuse
____Sleeping problems ____Suicidal thoughts ____Trembling
____Other_________________________________________
____Other_________________________________________

Check any areas in which mental health concerns are affecting your functioning.
____Emotionally ____Marriage/family ____Physically
____School ____Sexually ____Socially
____Work ____Other____________________________________

Case manager/ Trainee Agency Supervisor

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Date Date
 Substance Abuse Screening Form
Name: ____________________________________________
Date: _______________________
1. Do you have any history of treatment for substance abuse? ____Yes ____No
If yes, please answer the following question. Are you currently receiving treatment for substance
abuse? ____Yes ____No
2. Check any of the following which best describes your use of drugs or alcohol.
____I have never had any problems with substance abuse.
____I have no problems at this time.
____I have only a few concerns at this time.
____I am in recovery. (Last use _______________________________)
____I am an addict.
3. Do you have any family history of substance abuse? ____Yes ____No
4. When is the last time you used illegal drugs?
___Today
___Past week
___Past month
___Past 6 months
___Over 1 year
___Never
5. When is the last time you used alcohol?
___Today
___Past week
___Past month
___Past 6 months
___Over 1 year
___Never
6. When is the last time you misused prescription drugs?
___Today
___Past week
___Past month
___Past 6 months
___Over 1 year
___Never
7. Has anyone ever told you that you have a problem with substance abuse? ____Yes ____No
8. Have you ever tried to stop using substances but couldn’t? ____Yes ____No
9. Has the use of substances ever affected you in any of the following areas?
___Finances
___Friendships
___Health
___Marriage/Family
___School
___Work
____Other__________________________
____Other__________________________

Case manager/ Trainee Agency Supervisor

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Date Date
 Adaptive Functioning Screening Form

Name: ____________________________________________ Date: _______________________

Formed filled out by: ________________________ Relationship: _________________________

Note: This form usually is filled out by others who know the client fairly well.

1. Check any of the following areas in which there are problems in daily functioning when compared
to other people the same age.

Communication
___Expressing self to others adequately
___Speech is understandable
___Listening skills
___Follows directions
___Expresses self in writing
___Reading ability

Comments_____________________________________________________________________
______________________________________________________________________________

Social

___Interactions with other people

___Friendships
___Social skills
___Follows rules
___Vulnerability
Comments_____________________________________________________________________
______________________________________________________________________________
Activities of Daily Living
___Hygiene
___Health needs
___Household chores
___Cooking
___Money management
___Time management
Comments_____________________________________________________________________
______________________________________________________________________________
Case manager/ Trainee Agency Supervisor
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Date Date

Learning Disability Screening Form

 Name: ____________________________________________ Date: _______________________

CHILDREN AND ADULTS

1. Do you (or the child) have any history of being in special education? ____Yes ____No

If yes, for what reason(s)? _________________________________________________________

2. Have you (or the child) ever repeated a grade in school? ____Yes ____No
3. Have you (or the child) ever gone to school? ____Yes ____No
4. Have you (or the child) ever been diagnosed with a learning disability? ____Yes ____No
5. Check any of the following areas in which you have (or had) difficulties in school.
___Arithmetic ___Concentration ___Comprehension ___Disruptive ___Homework
___Hyperactivity ___Listening ___Low motivation ___Memorizing ___Need more testing time
___Note taking ___Physical problems ___Reading ___Spelling ___Writing
____Other__________________________
____Other_____________________________

ADULTS

6. Have you ever lost a job because of difficulties learning what was expected? ____Yes ____No
Describe______________________________________________________
7. Check any of the following in which you are currently have any difficulties.
____Arithmetic
____Comprehending reading material
____Filling out forms or job applications
____Learning new things
____Reading magazines
____Reading the newspaper
____Reading too slowly
____Seeing letters backwards or jumbled
____Spelling
____Writing
____Other_____________________________ Other _________________________________

Case manager/ Trainee Agency Supervisor

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Date Date

ADHD Screening Form

 Name: ____________________________________________ Date: _______________________

1. Is there any history of problems concentrating? ____Yes ____No

2. Is there any history of hyperactivity or impulsivity? ____Yes ____No
If yes (Items 1 or 2), please answer the following question: Currently receiving treatment for
ADHD? ____Yes ____No
3. Check any of the following symptoms that are being experienced.
___Often make careless mistakes
___Poor attention span
___Not following through
___Avoiding tasks that require effort
___Easily distracted
___Problems organizing
___Difficulty sustaining attention
___Often losing things
___Forgetful
___Fidgety
___Can’t sit still
___Hyperactive
___Impulsive
___Talk excessively
___ “On the go”
____Other_____________________________ Other _________________________________

4. How long have there been problems in these areas?_____________________________________

______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
5. Have other people (e.g., teachers, family, coworkers, and bosses) commented about any of these
concerns?
6. Check areas of functioning that have been affected by the symptoms in Item.

___Reading ___Recreation ___School ___Work ___Social ___Household chores

____Other_____________________________ Other_________________________________.

Case manager/ Trainee Agency Supervisor

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Date Date

Suicide Risk Screening/ Assessment

Completed by a regulated health care provider when indicated by screening or by clinical judgement.
Section A

1. Have you ever wished you were dead? __Yes __No

2. Have you ever thought about ending your life? ___Yes __No
If “yes” to questions 5 or 6, proceed through;
If “no” to both proceed to Section B
3. How often do you have these thoughts? __Daily __Weekly __Monthly
4. Do you have a plan about how you would end your life?
__Yes, Specify details
______________________________________________________________________________

__No
5. Have you ever felt that life was not worth living? __Yes __No
6. Did you ever wish you could go to sleep and just not wake up? __Yes __No
7. Is death something you’ve thought about recently? __Yes __No
8. Have things ever reached the point that you’ve thought of harming yourself__ Yes __No

Follow up with specific questions that ask about thoughts of death, self-harm, or suicide

9. Is death something you’ve thought about recently?

__Yes __No
10. Have things ever reached the point that you’ve thought of harming yourself? For individuals who
have thoughts of self-harm or suicide.
__Yes __No
11. When did you first notice such thoughts?
______________________________________________________________________________
______________________________________________________________________________
12. What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or
imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety,
agitation, psychosis)?
______________________________________________________________________________
______________________________________________________________________________
13. How often have those thoughts occurred (including frequency, obsessional quality, and
controllability)?
______________________________________________________________________________
______________________________________________________________________________
14. How close have you come to acting on those thoughts?
______________________________________________________________________________
______________________________________________________________________________
15. How likely do you think it is that you will act on them in the future?
______________________________________________________________________________
______________________________________________________________________________
16. Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding
knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?
______________________________________________________________________________
______________________________________________________________________________
17. What do you envision happening if you actually killed yourself (e.g., escape, reunion with
significant other, rebirth, and reactions of others)?
______________________________________________________________________________
______________________________________________________________________________
18. Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)
______________________________________________________________________________
______________________________________________________________________________
19. Do you have harming weapons available to you?
__Yes __ No
20. Have you made any particular preparations (e.g., purchasing specific items, writing a note or a
will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?
__Yes __No
21. Have you spoken to anyone about your plans?
__Yes __No
22. How does the future look to you?
______________________________________________________________________________
______________________________________________________________________________
23. What things would lead you to feel more (or less) hopeful about the future (e.g., treatment,
reconciliation of relationship, resolution of stressors)?
______________________________________________________________________________
______________________________________________________________________________
24. What things would make it more (or less) likely that you would try to kill yourself?
______________________________________________________________________________
______________________________________________________________________________
25. What things in your life would lead you to want to escape from life or be dead?
______________________________________________________________________________
______________________________________________________________________________
26. What things in your life make you want to go on living?
______________________________________________________________________________
______________________________________________________________________________
27. If you began to have thoughts of harming or killing yourself again, what would you do?
______________________________________________________________________________
______________________________________________________________________________

Section B:

Suicide Risk Factors

28. Have you attempted to end your life before? _____Yes, when?
______Within the past 3 months _____More than 3 months ago ___Other ___________

___No

29. Have there been any suicides or attempts among family or friends? _____Yes ___No

30. Have you ever been diagnosed with a mental illness? ____No
___Yes, if yes, Specify diagnosis
_________________________________________________________________

How do you feel about that diagnosis?

__________________________________________________

31. Are you experiencing any of the following (check all that apply)

 Increased or excessive substance use

 Feeling as if you are a burden
 Anger, anxiety or agitation
 Feeling trapped
 Lack of interest or energy
 Feeling overwhelmed
 Loss of independence/functional ability or loss of loved ones
 Changes in cognition/memory
 Withdrawal from friends, family or society
 Feelings of hopelessness/helplessness
 Feeling isolated
 Mood changes
 Lack of purpose
 Sleep disturbance
 Unmanaged health concerns, illness or aging changes
 Chronic pain or increase in physical pain

Protective Factors

a. Who do you turn to for support? (E.g., people, pets, services)

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
b. How have you gotten through tough times previously?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
c. What are some things you can do to help keep yourself safe or support mental well-
being?
 ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Action Items

Identified by a regulated health care provider applying clinical judgement in the context of the
situation. Refer to the Designated Living Options Suicide Risk Resource Guide for additional
information.

Suicide Risk is considered to be (select one)  Low  Moderate 

High/Imminent

Management Strategies (select all that apply). Document details in resident health record.

 Consult with Most Responsible Health Provider

 Notify others as applicable e.g., family, Case Manager, Unit Manager, etc.
 Implement/review interventions/strategies in the resident’s care plan
 Review interventions/strategies at care conference
 Consult/refer to other health care professional(s) or programs when clinically indicated
 Use Outcome Scales Report to track changes
 Monitor for signs of suicide risk
 Transfer to appropriate facility/unit or higher level of care
 Other ____________

Resident Monitoring Frequency (select one)

 Hourly  Every 4 hours  Constant/1:1 (ordered by MRHP)
 Every 2 hours  Site/unit routine _________  Other ___________________

Case manager/ Trainee Agency Supervisor

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Date Date