Patient Health Questionnaire (PHQ-9)

ATTENTION - PLEASE READ

StarCare Specialty Health System does not prescribe stimulants (including but not limited to Adderall, Vyvanse, Ritalin) or benzodiazepines (including but not limited to Xanax, Klonopin, Valium, Ativan).

Medication management resources outside of StarCare can be found by calling 211 Texas (dial 2-1-1) or visit their website at https://www.211texas.org.

If you are experiencing a mental health crisis, call 806-740-1414 or 800-687-7581.

StarCare Specialty Health System takes all necessary steps to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance. For more information, click the "Privacy Notice" link at the bottom of this form.

Instructions for Completing Intake Forms

Complete the following information for the person seeking services with StarCare Specialty Health System.

Completing this information ahead of time will shorten the time needed to complete your intake. Upon completion of the intake process, if eligible, you will be authorized for services based on your need. You will be assigned a case manager to assist you with accessing needed resources and services.

First Name

Middle Name

Last Name

Suffix

Date of Birth

mm/dd/yyyy

Over the last 2 weeks, how often have you been bothered by any of the following problems? For each question, please select the answer that most applies to you.

1. Little interest or pleasure in doing things

Not at all

Several days

More than half the days

Nearly every day

2. Feeling down, depressed, or hopeless

Not at all

Several days

More than half the days

Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

Not at all

Several days

More than half the days

Nearly every day

4. Feeling tired or having little energy

Not at all

Several days

More than half the days

Nearly every day

5. Poor appetite or overeating

Not at all

Several days

More than half the days

Nearly every day

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down

Not at all

Several days

More than half the days

Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all

Several days

More than half the days

Nearly every day

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?

Select the answer that most applies to you.

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

By typing my full name below, I certify the information provided is true and complete to the best of my knowledge. I understand typing my name is a legal signature and is considered the same as my handwritten signature.

Electronic Signature - Full Name of Person Completing this Form

Date Signed

mm/dd/yyyy

Send me a copy of my responses

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