Self-Assessment of Current Concerns
Name: _____________________________________ Date of Birth: _______________ SSN: _____________________
Are you covered by any health insurance (Medicaid, Medicare, Aetna, Healthlink, etc)?
Yes
No
If YES, what are you covered by (please list all insurance)? ____________________________________________
In the last THREE (3) days, have you had thoughts to kill yourself?
In the last THREE (3) days, have you had thoughts to kill other people?
Yes*
Yes*
No
No
*If yes – please utilize one of the following resources for immediate assistance: Call this agency’s 24/7 crisis line: (618)
465-4388 or (618) 639-2016, walk-in to the agency during business hours, go to the nearest Emergency Department at
your local hospital, or call the National Suicide Prevention Lifeline: (800) 273-8255
Have you been hospitalized for psychiatric reasons in the last 30 days?
Yes
No
If YES, where?________________________________________________________
Please answer the following questions to the best of your ability:
1.
What services are you seeking from WellSpring Resources? (Check all that apply.)
Counseling (Group)
Counseling (Individual)
Housing
Psychiatric/Medications Management
Case Management
DUI Services
Substance Abuse
Family Services
Methadone Treatment (Are you currently pregnant:
Yes
No; If pregnant, approximate due date: ____________)
Other_______________________________
2. Who referred you for services today?
Self
Friend/Family
DCFS
Court/Legal
Parole/Probation
Primary Doctor
Hospital
School
Other____________________________________________
3. What areas of your life are most impacted by your current symptoms?
Family relationships
Other personal relationships
Work/Occupational
School/Educational
Home Life
Other________________________________________________________
4. What, if any, are your urgent needs?:
Obtaining ID
Childcare
Child Support
Clothing/Food
Education
Medical Assistance
Employment
Healthcare Coverage
Home Services
Housing
Legal Assistance
Transportation
Veteran’s Assistance
Vocational Rehabilitation
Financial Assistance _______________________________________________________________
Other __________________________________________________________________________
5. Other information:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
***PLEASE TURN OVER AND COMPLETE THE SECOND SIDE***
For office use only:
# of dependents________________
Household income and source of income_________________________________
Please check all concerns that apply:
Crying spells
Depressed mood most days
Loss of interest in fun activities
Loss of appetite
Excessive appetite
Cannot seem to sleep
Sleep too much
A lot of nervous energy (pacing)
Feeling of being slowed down
Loss of energy (tired all day)
Excessive guilt/worthlessness
Cannot seem to maintain focus
Frequent thoughts of death
Thinking about ending my life
Feeling invincible or God-like
Cannot seem to quit talking
Feeling of racing thoughts
Easily distracted
Start several activities at once
Risky or impulsive behavior
Spend money inappropriately
Risky sexual encounters
Panic attacks
Avoid public places
Avoid certain places
Fear “going crazy”
Fear embarrassment
Fears are excessive/irrational
Thoughts cause excessive anxiety
Thoughts are irrational
Compulsive behavior
Frequent hand washing
Frequent checking
Tolerance to substances
6.
Behaviors are irrational
Experienced a traumatic event
Intrusive thoughts about trauma
Dreams about the trauma
Flashback about the trauma
Avoid anything related to trauma
Feeling detached from people
Outbursts of anger
Exaggerated startle response
Always on alert for danger
Unable to feel feelings
Lack of future goals
Always irritable
Muscles always tense
Constant worry/anxiety
Constant paranoia
Thoughts don’t make sense
Seeing things that others don’t
Hearing things that others don’t
Lack of care for hygiene
Self-Medicating
Using alcohol excessively
Using street/illegal drugs
Taking too much medication
Dependent upon substances
Abuse of substances
Excessive cigarette smoking
Excessive chewing tobacco use
Diagnosis on Autism Spectrum
Developmental Disorder
Diagnosis of ADHD
Makes careless mistakes
Difficulty with attention
Withdrawal from substances
Does not seem to listen
Does not finish homework/chores
Difficulty with organization
Avoids schoolwork
Loses items related to schoolwork
Easily distracted
Often forgetful
Does not seem to listen
Fidgets/squirms in seat
Leaves classroom seat often
Excessive energy
Loud during quiet times
“On the go” all the time
Talks excessively
“Blurts out answers”
Difficulty waiting turn
Interrupts frequently
Cruel to people
Cruel to animals
Fire setting
Destroys others’ property
Lying
Running away from home
Staying out late at night
Spiteful/Vindictive
Misses a lot of school
Bullies others
Physical fighting
Use of a weapon to harm a peer
Argues with adults
Easily annoyed by others
Fire setting
Here to comply with mandate
Legal charges due to substances
When did you start noticing the onset of symptoms?
1 week
2 weeks
Life long issue
1 month
3 months
New-No previous history
6 months or longer
Recurrent-Previous history
7. Were there any identifying triggers to your symptoms?
Yes
No
If yes, please describe: ____________________________________________________
8. How severe are the symptoms?
Mild (minimal symptoms)
Moderate
Severe (majority of symptoms)
9. Have you ever served in the US Military (regardless of discharge status)?
Yes
No
To start services please call (618) 462-2331 or 618-639-2010 to set-up an initial intake OR use our walk-in hours M-F
9am-2pm. Those with commercial healthcare plans (private insurance) and Medicare Only/supplemental plans are
encouraged to call to set-up an appointment to ensure being seen by an in-network provider.
For office use only:
# of dependents________________
Household income and source of income_________________________________