Carrousel Therapy Center New Referral Form CLIENT INFORMATION FIRST NAME & INITIAL * LAST NAME * FULL NAME * PARENT/GUARDIAN NAME COUNTY * SelectBrevardOrangeOsceolaPolkSeminoles REFERRAL DATE * DATE OF BIRTH * SEX * SelectMaleFemele ETHNIC SelectHispanic or LatinoNon Hispanic or Latino RACE SelectAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite SSN HOME PHONE * CELL PHONE * PREFERRED PHONE * SelectHomeCell ADDRESS * CITY * STATE * ZIP CODE * LANGUAGE PREFERENCE * English Spanish SCHOOL GRADE ESE CLIENT ID SERVICE REQUIRED SERVICE REQUIRED (Select all that apply) * PSYCHIATRIC EVALUATION MENTAL HEALTH COUNSELOR MEDICATION MANAGEMENT TARGETED CASE MANAGEMENT PSYCHOSOCIAL REHABILITATION SERVICES PSYCHOLOGICAL TESTING REASON FOR REFERRAL REASON FOR REFERRAL (Select all that apply) * DEPRESSION STEALING VERBAL AGGRESSION INAPPROPRIATE SEXUAL BEHAVIOR NON COMPLIANCE TRAUMA ANXIETY SUBSTANCE ABUSE ADD/ADHD OTHEROTHER CURRENT OR PREVIOUS TREATMENT CURRENT TREATMENT (Please Explain) PREVIOUS TREATMENT (Please Explain) DIAGNOSIS (Please Explain) MEDICATIONS (Please Explain) COMMENTS PHYSICIAN INFORMATION PHYSICIAN’S NAME PHYSICIAN’S NPI PHYSICIAN’S PHONE PHYSICIAN’S FAX INSURANCE INFORMATION INSURANCE INFO * AETNA SIMPLY MAGELLAN MEDICAID MEDICARE FLORIDA HELATH SOLUTIONS SELF PAY CIGNA FREEDOM SUNSHINE HUMANA UNITED HELATH CARE TRICARE MOLINA OSCAR OtherOther INSURANCE ID * INSURANCE OTHER ID REFERRAL SOURCE REFERRAL FULL NAME * REFERRAL AGENCY REFERRAL EMAIL * REFERRAL PHONE REFERRAL FAX REFERRAL TAKEN BY REFERRAL REQUESTED THERAPIST: DISCLAIMER Patient Depression Questionnaire (PHQ-9) Patient ID: Date Patient Name Patient Name First First Last Last Over the last 2 weeks, how often have you been bothered by any of the following problems? 0-4 Minimal or non Monitor; may not require treatment 5-9 Mild 10-14 Moderate (Use clinical judgment {symptom duration, functional impairment} to determine necessity of treatment) 15-19 Moderate severe 20-27 Severe (Warrants active treatment with psychotherapy, medications, or combination) 1. Little interest or pleasure in doing things Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 2. Feeling down, depressed, or hopeless Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 3. Trouble falling or staying asleep, or sleeping to much Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 4. Feeling tired or having little energy Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 5. Poor appetite or overeating Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 7. Trouble concentrating or things, such as reading the newspaper or watching television Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 8. Moving or speaking so slowly that other people could notice, or the opposite (moving a lot more that normal) Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) 9. Thoughts that you would be better off dead, or of hurting yourself Please select oneNot at all (0)Several days (1)More than half the days (2)Nearly every day (3) Ranking — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 0-4 Minimal or Non-Monitor — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 5-9 Mild — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 10-14 Moderate — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 15-19 Moderate Severe — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 20-27 Severe CRITICAL ACTIONS: Perform suicide risk assessment in patients who respond positively to item 9 “Thoughts that you would be better off dead or of hurting yourself in some way.” Rule out bipolar disorder, normal bereavement, and medical disorders causing depression. Hamilton Anxiety Rating Scale (HAM-A) Patient Name Patient Name First First Last Last Date Bellow is a list of phrases that describe certain feeling that people have. Please select one of the five responses for each of the 14 questions. 0 = Not Present 1 = Mild 2 = Moderate 3 = Severe 4 = Very Severe 1. Anxious Mood 0 1 2 3 4 Worries, anticipation, of the words, fearful anticipation, irritability. 2. Tension 0 1 2 3 4 Feeling of tension, fatiguability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax. 3. Fears 0 1 2 3 4 Of dark, of strangers, of being alone, of animals, of trafic, of crowds. 4. Insomnia 0 1 2 3 4 Difficulty in falling to asleep, broken sleep, unsatisfying sleep, and fatigue on walking, dreams, nightmares, night terrors. 5. Intellectual 0 1 2 3 4 Difficulty in concentration, poor memory 6. Depressed Mood 0 1 2 3 4 Loss of interest, lack of pleasure in hobbies, depression, early walking, diurnal swing. 7. Somatic(muscular) 0 1 2 3 4 Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone. 8. Somatic(sensory) 0 1 2 3 4 Tinnitus, blurring of vision, hot and cold flashes, feeling of weakness, pricking sensation. 9. Cardiovascular Symptoms 0 1 2 3 4 Tachycardia, palpitations pain in chest, throbbing of vessels, fainting feelings, missing beats. 10. Respiratory Symptoms 0 1 2 3 4 Pressure or constriction in chest, choking feeling, sighing, dyspnea. 11. Gastrointestinal Symptoms 0 1 2 3 4 Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation. 12. Genitourinary Symptoms 0 1 2 3 4 Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence. 13. Autonomic Symptoms 0 1 2 3 4 Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension, headache, raising of hair. 14. Behavior at Interview 0 1 2 3 4 Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc. Ranking — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 17 None to Mild Severity — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 18-24 Mild to Moderate Severity — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 25-30 Moderate to Severe Severity — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 31-56 Severe Severity Submit If you are human, leave this field blank. Δ
