Cornerstone Treatment Center Mental Health Screening

Client First Name

Client Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Birthday

Month

Day

Year

Current Age

Address

City

State

Phone

Are you Hispanic or Latino?

Yes

1.Did you start any new medications or have a change in medications?

Yes

2.Do you feel that you live in a safe and healthy environment?

Yes

3.Do you feel supported by your family?

Yes

4.Do you feel threatened or bullied by peers?

Yes

5.Do you experience "ups" as well as "downs: with your mood?

Yes

6.Do you experience hyperactivity or inattention in your daily activities?

Yes

7.Do you lack interest in activities, hobbies, and what is happening around you?

Yes

8.Are you experiencing any type of psychosis, (hearing or seeing anything unusual that others can't)?

Yes

9.Do you at times feel that you are being watched or followed when there is no evidence of a threat?

Yes

10.Have you experienced any type of traumatic event that has been difficult to overcome?

Yes

11. Have you experienced any type of trauma within the last 24-72 hrs?

Yes

12. Have you self-harmed within the last 24-72hrs?

Yes

13. Do you at times wish you went to sleep and never wake up?

Yes

15. On a scale of 0 to 3, how bad are your thoughts of suicide today?

0-no thoughts

1-some thoughts

2-desire to act on thoughts

3-plan and/or intent

Do you have a suicide plan, or is there a specific person you feel homicidal against? Please explain

If your experiencing panic attacks, please specify frequency (#/day)

16. How many meals did you eat yesterday?

Food allergies?

17. Weight loss or gain of 10 lbs or more in the last 3 months

Yes

If yes, please indicate

18. Any eating habits or behaviors that may indicate an eating disorder: bingeing, or induced vomiting?

Yes

19. Is this an increase or decrease in appetite?

Yes

20. Any past diagnosis of anorexia, bulimia or other eating disorder?

21. Dental problems or dental issues that interfere with eating.

22. Are you having any sleep difficulties (falling/staying asleep/waking up)?

Yes

23. Identify healthy coping skills you are currently practicing

24. What unhealthy coping skills are you currently practicing

25. Within the last 72 hours, are you currently relying on alcohol and drugs as a coping mechanism?

Yes

If yes, please list

27. Who can you specifically talk with about your mental health needs? Who will be involved with your treatment?

28. What are you grateful for today?

29. Please identify one thing you would like to discuss in session?

30. Who referred you/ How did you hear about us?

Insurance-We accept Medicaid, Medicare , and Commercial Plans

Subscriber name

Member ID

Signature

Date

Month

Day

Year

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

I understand that during the course of my care or participation in the program, it may be determined that additional services, evaluations, or specialized treatment outside of this program may be beneficial to my health, safety, or well-being.

By signing above, I acknowledge and give consent for the program and its staff to refer me to appropriate external providers, agencies, or professionals when deemed necessary to support my care.

I understand that any referral will be made in accordance with applicable privacy laws and regulations, including the protection of my confidential information.

I also understand that I have the right to ask questions regarding any referral and may choose whether to pursue services with the recommended provider.

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