Optional Health Assessment Modules Form Page 8
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27UR Number:
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
INTERPRETATION/SCORE
Score of 0*
No symptoms of depression, anxiety and/or somatic complaints indicated at this time.
Action: Re-screen using the PsyCheck Screening Tool after 4 weeks if indicated by past mental health questions or other information.
Otherwise monitor as required.
Score of 1–4*
Some symptoms of depression, anxiety and/or somatic complaints indicated at this time.
Action: Give the first session of the PsyCheck Intervention and screen again in 4 weeks.
Score of 5+*
Considerable symptoms of depression, anxiety and/or somatic complaints indicated at this time.
Action: Offer Sessions 1–4 of the PsyCheck Intervention.
Re-screen using the PsyCheck Screening Tool at the conclusion of four sessions.
If no improvement in scores evident after re-screening, consider referral.
* Regardless of the client’s total score on the SRQ, consider intervention or referral if in significant distress.
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
7
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