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Enhanced Care Management (ECM) Comprehensive Assessment - Section D

1.Today's Date
Today's Date
2.First Name
3.Last Name
4.Date of Birth
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?
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?
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?