Patient Health Questionnaire (PHQ-9) – Cognitive Behavior Institute

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 things
- 2. Feeling down, depressed, or hopeless
- 3. Trouble falling or staying asleep, or sleeping too much
- 4. Feeling tired or having little energy
- 5. Poor appetite or overeating
- 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
- 7. Trouble concentrating on things, such as reading the newspaper or watching television
- 8. 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 usual
- 9. Thoughts that you would be better off dead or of hurting yourself in some way
- If 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?
- I 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.