Mental Health Screening Form-Iii printable pdf download

Mental Health Screening Form-Iii

Mental Health Screening Form-III

Instructions: Read each question and circle the appropriate response. Please note, each item refers to your

entire life history, not just your current situation. This is why each question begins with “Have you ever…..”

1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an

emotional problem?

YES

2. Have you ever felt you needed help with your emotional problems, or have you had people tell you that

you should get help for your emotional problems?

YES

3. Have you ever been advised to take medication for anxiety, depression, and/or hearing voices or for any

other emotional problem?

YES

4. Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?

YES

5. Have you ever heard voices no one else could hear or seen objects or things which others could not see?

YES

6. Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble

concentrating and making decisions, or thought about killing yourself?

YES

7. Have you ever attempt to kill yourself?

YES

8. Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending

social events, being in a crowd, being alone, being in places where it may be hard to escape or get help?

YES

9. Have you ever given in to an aggressive urge or impulse, on more than one occasion that resulted in

serious harm to others or led to the destruction of property?

YES

10. Have you ever felt that people had something against you, without them necessarily saying so, or that

someone or some group may be trying to influence your thoughts or behaviors?

YES

11. Have you ever experienced any emotional problems associated with your sexual interests, your sexual

activities, or your choice of sexual partner?

YES

Mental Health Screening Form-Iii