Enhanced Care Management (ECM) Comprehensive Assessment - Section D

Question Title

1. Today's Date

Today's Date

Date

Question Title

2. First Name

Question Title

3. Last Name

Question Title

4. Date of Birth

Date of Birth

Date

Question Title

5. Email

Question Title

6. SMS Text

Question Title

7. Has a healthcare or mental health provider ever told you that you have a mental health diagnosis?

Yes

Question Title

8. What diagnosis have you been given?

No diagnosis was ever given

Depression

Bipolar disorder

Schizophrenia

Anxiety

PTSD

Other (please specify)

Question Title

9. Over the last two weeks have you experienced a reduction in interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Question Title

10. Over the last two weeks have you felt down, depressed or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Question Title

11. Over the last two weeks have you had thoughts that you would be better off dead or of hurting yourself in some way?

Not at all

Several days

More than half the days

Nearly every day

Question Title

12. How would you describe your stress level when you feel tense, nervous, anxious, or can’t sleep at night because their mind is troubled?

Not at all

Lightweight

Very High

Moderately High

Other (please specify)

Question Title

13. Have you ever experienced traumatic events such as such as being in a serious accident, physical/emotional abuse, sexual assault or abuse, being in a war, seeing someone killed or assaulted, having a loved one die by suicide, being bullied/discriminated against, or other events/experiences that were distressing or disturbing to you?

Yes, and here is a brief description of what happened:

Question Title

14. Have you had any changes in thinking, remembering, or making decisions?

Yes

Question Title

15. In the past month, have you felt worried, scared or confused that something may be wrong with your mind or memory?

Yes

Question Title

16. Has a healthcare provider ever told you or your family that when you were a child or adult that you had a developmental delay, disability, or brain injury that impacted your ability to think clearly (for example, traumatic brain injury, autism spectrum disorder, ADHD, learning disability)?

Yes

Unsure

Question Title

17. In the past six months, how often have you used alcohol?

Never

1 to 2 times

Monthly

Weekly

Daily

Question Title

18. In the past six months, how often have you used Nicotine products (Cigarette, vaping, chewing tobacco)?

Never

1 to 2 times

Monthly

Weekly

Daily

Question Title

19. In the past six months, how often have you used prescription drugs not as prescribed (such as Pain medicines, ADHD medicines, and Sleeping pills)?

Never

1 to 2 times

Monthly

Weekly

Daily

Question Title

20. In the past six months, how often have you used Marijuana?

Never

1 to 2 times

Monthly

Weekly

Daily

Question Title

21. In the past six months, how often have you used other substances (such as cocaine, meth, heroin, hallucinogens, inhalants, and/or designer drugs)?

Never

1 to 2 times

Monthly

Weekly

Daily

Question Title

22. Have you ever felt you ought to cut down on your drinking or drug use?

Yes

Question Title

23. Would you like to talk with someone about your substance use, especially if you are thinking of quitting or cutting back?

Yes

Enhanced Care Management (ECM) Comprehensive Assessment - Section D

Question Title

* 1. Today's Date

Question Title

* 2. First Name

Question Title

* 3. Last Name

Question Title

* 4. Date of Birth

Question Title

* 5. Email

Question Title

* 6. SMS Text

Question Title

* 7. Has a healthcare or mental health provider ever told you that you have a mental health diagnosis?

Question Title

* 8. What diagnosis have you been given?

Question Title

* 9. Over the last two weeks have you experienced a reduction in interest or pleasure in doing things?

Question Title

* 10. Over the last two weeks have you felt down, depressed or hopeless?

Question Title

* 11. Over the last two weeks have you had thoughts that you would be better off dead or of hurting yourself in some way?

Question Title

* 12. How would you describe your stress level when you feel tense, nervous, anxious, or can’t sleep at night because their mind is troubled?

Question Title

Question Title

* 14. Have you had any changes in thinking, remembering, or making decisions?

Question Title

* 15. In the past month, have you felt worried, scared or confused that something may be wrong with your mind or memory?

Question Title

* 16. Has a healthcare provider ever told you or your family that when you were a child or adult that you had a developmental delay, disability, or brain injury that impacted your ability to think clearly (for example, traumatic brain injury, autism spectrum disorder, ADHD, learning disability)?

Question Title

* 17. In the past six months, how often have you used alcohol?

Question Title

* 18. In the past six months, how often have you used Nicotine products (Cigarette, vaping, chewing tobacco)?

Question Title

* 19. In the past six months, how often have you used prescription drugs not as prescribed (such as Pain medicines, ADHD medicines, and Sleeping pills)?

Question Title

* 20. In the past six months, how often have you used Marijuana?

Question Title

* 21. In the past six months, how often have you used other substances (such as cocaine, meth, heroin, hallucinogens, inhalants, and/or designer drugs)?

Question Title

* 22. Have you ever felt you ought to cut down on your drinking or drug use?

Question Title

* 23. Would you like to talk with someone about your substance use, especially if you are thinking of quitting or cutting back?

1. Today's Date

2. First Name

3. Last Name

4. Date of Birth

5. Email

6. SMS Text

7. Has a healthcare or mental health provider ever told you that you have a mental health diagnosis?

8. What diagnosis have you been given?

9. Over the last two weeks have you experienced a reduction in interest or pleasure in doing things?

10. Over the last two weeks have you felt down, depressed or hopeless?

11. Over the last two weeks have you had thoughts that you would be better off dead or of hurting yourself in some way?

12. How would you describe your stress level when you feel tense, nervous, anxious, or can’t sleep at night because their mind is troubled?

14. Have you had any changes in thinking, remembering, or making decisions?

15. In the past month, have you felt worried, scared or confused that something may be wrong with your mind or memory?

16. Has a healthcare provider ever told you or your family that when you were a child or adult that you had a developmental delay, disability, or brain injury that impacted your ability to think clearly (for example, traumatic brain injury, autism spectrum disorder, ADHD, learning disability)?

17. In the past six months, how often have you used alcohol?

18. In the past six months, how often have you used Nicotine products (Cigarette, vaping, chewing tobacco)?

19. In the past six months, how often have you used prescription drugs not as prescribed (such as Pain medicines, ADHD medicines, and Sleeping pills)?

20. In the past six months, how often have you used Marijuana?

21. In the past six months, how often have you used other substances (such as cocaine, meth, heroin, hallucinogens, inhalants, and/or designer drugs)?

22. Have you ever felt you ought to cut down on your drinking or drug use?

23. Would you like to talk with someone about your substance use, especially if you are thinking of quitting or cutting back?