Mary Ryder Home IRTS Screening Survey

Mary Ryder Home

Thank you for your interest in Mary Ryder Home! The following questions can help determine if you or your loved one is a good fit for Mary Ryder Home’s Intensive Residential Treatment Setting (IRTS) program. Questions should be answered with the potential resident in mind.

*1.What is the age of the individual?(Required.)

*2.What is the gender of the individual seeking residential care?(Required.)

Female

Male

Other

*3.Does the individual needing services have one of these pre-existing mental health diagnoses? (select all that apply)(Required.)

Schizophrenia

Schizoaffective Disorder

Bipolar I Disorder

Psychotic Disorder NOS

Major Depressive Disorder – Single Episode (if 60+ years old)

Post Traumatic Stress Disorder (PTSD)

Anxiety Disorder

Schizophreniform Disorder

Delusional Disorder

Bipolar II Disorder

Major Depressive Disorder – Recurrent

Obsessive Compulsive Disorder (OCD)

Borderline Personality Disorder

None of the above

*4.Has the individual experienced any of the following:(Required.)

Undergone psychiatric treatment more intensive than outpatient more than once in a lifetime

Experienced an episode of continuous residential care other than hospitalization, long enough to disrupt normal living

Exhibited psychiatric disability for one year or more

Required psychiatric disorder treatment longer than six months

None of the above

*5.Does the individual meet any of the following criteria?(Required.)

Can tolerate regular interaction with peers

Has significant difficulties with activities of daily living (dressing, bathing, managing a household, etc. )

Requires periodic redirection to avoid behaviors potentially harmful to themselves or others

Has had extended or repeated psychiatric hospitalizations or crisis episodes in the past six months

None of the above

See how easy it is to create surveys and forms.

Privacy & Cookie Notice