Psychiatric Intake Form

Patient Demographics

Full Name

Date of Birth

Age

Gender

Address

Phone Number

Email Address

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Problem	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way

PHQ-9 Total Score

0 / 27

3508 Pinkham Way
Raliegh
NC, 27616 United States

952-737-3202/(984) 737-3202