Over the last two weeks, how often have you been bothered by the following problems?
Not at all
Several days
More than half
Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
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Credify Supplemental Intake
Additional screening questions — auto-linked to client record
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Auto-populated from the intake form: Client name and date have been pre-filled. Please complete the supplemental questions below.
Client Record
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Contact InformationAdded by Credify
Question 1 of 5 — Rate your current stress levelAdded by Credify
Question 2 of 5 — Current symptoms (select all that apply)Added by Credify
Question 3 of 5 — Medication historyAdded by Credify
Question 4 of 5 — Goal commitmentAdded by Credify
1 - Not at all5 - Moderately10 - Fully committed
Question 5 of 5 — Emergency contactAdded by Credify
PHQ-9 Depression ScreeningAdded by Credify
Over the last two weeks, how often have you been bothered by any of the following problems?
Not at all
Several days
More than half the days
Nearly every day
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 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