I understand that this information will be kept confidential.
Have you ever or are you currently experiencing any of the following?
If yes, please describe. You can include when it started, how often it occurs, and how intense the symptoms are on a scale from 0-10 (with 10 being the highest?)
Depressed mood (if yes, for how long?)
Loss of a loved one (Who died and when?)
Loss or transition (i.e. move, retirement, job loss)
Repetitive/obsessive thoughts behaviors
Sense of hopelessness and/or worthlessness
Thoughts of harming another
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