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Mental health questionnaire13-20yrs_english
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Mental health questionnaire13-20yrs_english

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  • 1. MENTAL HEALTH QUESTIONNAIRE Maryland Healthy Kids ProgramChild’s Name: _________________________________________ Date of Birth: ________________Managed Care Organization: __________________________ Child’s Medicaid #: ______________ Ages 13 – 20 yearsCheck all answers that may apply. This form may be filled out by the patient, parent/guardianor health care provider. Do you have trouble paying attention? ………..……………………………... Yes No Do you often: Feel distrustful of others …………………………………………….. Yes No Have strange thoughts ………………………………………………….. Yes No Hear voices ……………………………………………………………... Yes No Have to do things the same way or keep repeating them .………… Yes No Do you have problems at school with: Behavior ………………………………………………………………… Yes No Grades ………………………………………………………………….. Yes No Skipping classes ………………………………………………………… Yes No Do you worry about your: Eating …………………………………………………………………… Yes No Sleep ……………………………………………………………………. Yes No Weight ………………………………………………………………….. Yes No Do you have trouble making or keeping friends? ...…………………………. Yes No Do you often feel: Sad …………………………….………………………………………… Yes No Angry ……………………………………………………………………… Yes No Nervous or afraid ……………………………………………………….. Yes No Have you thought about or done any of the following: Destroy property ……………………………………………………….. Yes No Hurt animals ……………………………………………………………. Yes No Set fire .…………………………………………………………...…….. Yes No Listen to music with violent message ……………………….……….. Yes No Use alcohol .……………………………………………………………. Yes No Use drugs .……………………………………………………………… Yes No Smoke cigarettes ……………………………………………………….. Yes No Sex without protection………………………………………………….. Yes No Suicide attempt ……………………………………………….…………. Yes No (Continued on back) MARYLAND HEALTHY KIDS PROGRAM Maryland Department of Health and Mental Hygiene HealthChoice and Acute Care Administration, Division of Healthy Kids 6/06
  • 2. MENTAL HEALTH QUESTIONNAIRE Maryland Healthy Kids Program Page TwoIs there a history of injuries, accidents? …………………………………….. Yes NoIf yes, please specify: _______________________________________________Is there any history of maltreatment or abuse? ……………………………… Yes NoIf yes, please specify: _______________________________________________Is there a recent stress on the family or child such as : Birth of a child …………………………………………………………. Yes No Moving ……………………………………………………………………. Yes No Divorce or separation …………………………………………………… Yes No Death of a close relative .……………………………………………….. Yes No Fired or laid off ………………………………………………………… Yes No Legal problems …………………………………………………………. Yes No Others (Please specify): _________________________________ Yes NoDo you have other parenting concerns? ……………………………………… Yes NoPlease specify: _____________________________________________________Provider: Give details of all Positive findings._______________________________________________ _________________Provider’s Signature DateProvider’s Phone: (__ __ __) /__ __ __ /__ __ __ __ THIS FORM MAY BE USED FOR MENTAL HEALTH REFERRALSChild Receiving Referral: ___________________________________________________Child’s Address: __________________________________________________________Child’s Phone: ___________________________________________________________Referred to: _____________________________________________________________Reason for Referral: ______________________________________________________ _______________________________________________________________________ MARYLAND HEALTHY KIDS PROGRAM Maryland Department of Health and Mental Hygiene HealthChoice and Acute Care Administration, Division of Healthy Kids 6/06