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Elevate Healthcare

 Mental Health Screening 

Please complete form to begin mental health screening process.
1. Did you start any new medications or have a change in medications?
2. Do you feel that you live in a safe and healthy environment?
3. Do you feel supported by your family?
4. Do you feel threatened or bullied by peers?
5. Do you experience ‘ups’ as well as ‘downs’ with your mood?
6. Do you experience hyperactivity or inattention in your daily activities?
7. Do you lack interest in activities, hobbies, and what is happening around you?
8. Are you experiencing any type of psychosis, (hearing or seeing anything unusual that others can't)?
9. Do you at times feel that you're being watched or followed when there is no evidence of a threat?
10. Have you experienced any type of traumatic event that has been difficult to overcome?
11. Have you experienced any type of trauma within the last 24-72 hrs?
12. Have you self-harmed within the last 24-72 hrs?
13. Do you at times wish you went to sleep and never woke up?
14. On a scale of 0 to 5, how down, depressed, or hopeless do you feel?
15. On a scale of 0 to 3, how bad are your thoughts of suicide today?
16. On a scale of 0 to 5, please rate your anxiety today.
Is this an increase or decrease in appetite?
18. Are you having any sleep difficulties (falling/staying asleep/waking up)?
21. Within the last 72 hours, are you currently relying on alcohol and drugs as a coping mechanism?
22. Activities of Daily Living (ADLs): Do you experience any difficulty in your ability to perform the following activities?

I give consent to Elevate Healthcare to provide a mental health screening and schedule an Intake assessment. I understand minors under the age of 18 must have parent / guardian approval prior to submitting. Upon submission a member from admissions will send a HIPPA secured link to complete an intake packet. 


In the event of an emergency please call 911 or go to the nearest emergency room. 

Thanks for choosing Elevate Healthcare!

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