PATIENT HEALTH QUESTIONNAIRE-9 ( P H Q - 9 )Name*Email* Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing thingsNot at allSeveral daysMore than half the daysNearly every day2. Feeling down, depressed, or hopelessNot at allSeveral daysMore than half the daysNearly every day3. Trouble falling or staying asleep, or sleeping too muchNot at allSeveral daysMore than half the daysNearly every day4. Feeling tired or having little energyNot at allSeveral daysMore than half the daysNearly every day5. Poor appetite or overeatingNot at allSeveral daysMore than half the daysNearly every day6. Feeling bad about yourself — or that you are a failure or have let yourself or your family downNot at allSeveral daysMore than half the daysNearly every day7. Trouble concentrating on things, such as reading the newspaper or watching televisionNot at allSeveral daysMore than half the daysNearly every day8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usualNot at allSeveral daysMore than half the daysNearly every day9. Thoughts that you would be better off dead or of hurting yourself in some wayNot at allSeveral daysMore than half the daysNearly every dayIf you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultI have read, understand and agree to the Medication Management Agreement.I have read, understand and agree to the Medication Management Agreement.* I have read, understand agree to the Electronic Communication Policy.I have read, understand agree to the Electronic Communication Policy.* I have read, understand and agree to the Client Rights & Responsibilities.I have read, understand and agree to the Client Rights & Responsibilities.* I have read, understand and agree to the Notice of Privacy Practices.I have read, understand and agree to the Notice of Privacy Practices.* I have read, understand and agree to the Financial Obligation Policy.I have read, understand and agree to the Financial Obligation Policy.* I have read, understand and agree to the Distance Counseling Procedures.I have read, understand and agree to the Distance Counseling Procedures.* I have read and understand the above information, have had an opportunity to ask questions about this information, and I consent to behavioral health treatment through the Cognitive Behavior Institute as outlined above. Scroll Up
