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HIPAA
Compliance
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English (US)
Spanish (Latin America)
1
Your Provider
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Julio Lagos, LCSW
Neri Singer, ACSW
Ashley Lee, LCSW
Kelli Clark, LCSW
Heather Ayers-Cluff, LCSW
Brenda Cordova, ACSW
Benica Foster, ACSW
Armando Naranjo, LCSW
Jessica Hodge, LMFT
Sweeta Khosrawi, APCC
Pilar Farfan, MA
Ke Chen, MSWI
Myrna Kaipov, MSWI
Kendall Setum, AMFT
Amelia Garcia, APCC
Nicole Lippert, LCSW
Julie Aronowitz, ACSW
Karla Mansilla, ACSW
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2
Your Initials
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3
Your Full Name (Client's Name)
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First Name
Last Name
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4
PHQ9 - Over the last two weeks, how often have you been bothered by any of the following problems?
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NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERY DAY
01. Little interest or pleasure in doing things
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02. Feeling down depressed or hopeless
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03. Trouble falling or staying asleep, or sleeping too much
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04. Feeling tired or having little energy
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05. Poor appetite or overeating
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06. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
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07. Trouble concentrating on things, such as reading the newspaper or watching television
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08. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual
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09. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way
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01. Little interest or pleasure in doing things
02. Feeling down depressed or hopeless
03. Trouble falling or staying asleep, or sleeping too much
04. Feeling tired or having little energy
05. Poor appetite or overeating
06. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
07. Trouble concentrating on things, such as reading the newspaper or watching television
08. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual
09. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way
NOT AT ALL
Row 0, Column 0
SEVERAL DAYS
Row 0, Column 1
MORE THAN HALF THE DAYS
Row 0, Column 2
NEARLY EVERY DAY
Row 0, Column 3
NOT AT ALL
Row 1, Column 0
SEVERAL DAYS
Row 1, Column 1
MORE THAN HALF THE DAYS
Row 1, Column 2
NEARLY EVERY DAY
Row 1, Column 3
NOT AT ALL
Row 2, Column 0
SEVERAL DAYS
Row 2, Column 1
MORE THAN HALF THE DAYS
Row 2, Column 2
NEARLY EVERY DAY
Row 2, Column 3
NOT AT ALL
Row 3, Column 0
SEVERAL DAYS
Row 3, Column 1
MORE THAN HALF THE DAYS
Row 3, Column 2
NEARLY EVERY DAY
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NOT AT ALL
Row 4, Column 0
SEVERAL DAYS
Row 4, Column 1
MORE THAN HALF THE DAYS
Row 4, Column 2
NEARLY EVERY DAY
Row 4, Column 3
NOT AT ALL
Row 5, Column 0
SEVERAL DAYS
Row 5, Column 1
MORE THAN HALF THE DAYS
Row 5, Column 2
NEARLY EVERY DAY
Row 5, Column 3
NOT AT ALL
Row 6, Column 0
SEVERAL DAYS
Row 6, Column 1
MORE THAN HALF THE DAYS
Row 6, Column 2
NEARLY EVERY DAY
Row 6, Column 3
NOT AT ALL
Row 7, Column 0
SEVERAL DAYS
Row 7, Column 1
MORE THAN HALF THE DAYS
Row 7, Column 2
NEARLY EVERY DAY
Row 7, Column 3
NOT AT ALL
Row 8, Column 0
SEVERAL DAYS
Row 8, Column 1
MORE THAN HALF THE DAYS
Row 8, Column 2
NEARLY EVERY DAY
Row 8, Column 3
1
of 9
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5
PHQ-9 Score Outcomes
Interpretation for PHQ-9 SCORE:
0-4
= Minimal to None (monitor)
5-9
= Mild Depression severity (use clinical judgment)
10-14
= Moderate Depression severity (active treatment)
15-19
= Moderately Severe Depression severity (active treatment)
20-27
= Severe Depression severity (active treatment, consider medication management referral)
CLIENT'S PHQ-9 SCORE FOR THIS DATE
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6
GAD7 - Over the last two weeks, how often have you been bothered by any of the following problems?
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NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERY DAY
A) Feeling nervous, anxious, or on edge?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
B) Not being able to stop or control worrying?
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C) Worrying too much about different things?
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D) Trouble relaxing?
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E) Being so restless that it's hard to sit still?
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F) Becoming easily annoyed or irritable?
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G) Feeling afraid as if something awful might happen?
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A) Feeling nervous, anxious, or on edge?
B) Not being able to stop or control worrying?
C) Worrying too much about different things?
D) Trouble relaxing?
E) Being so restless that it's hard to sit still?
F) Becoming easily annoyed or irritable?
G) Feeling afraid as if something awful might happen?
NOT AT ALL
Row 0, Column 0
SEVERAL DAYS
Row 0, Column 1
MORE THAN HALF THE DAYS
Row 0, Column 2
NEARLY EVERY DAY
Row 0, Column 3
NOT AT ALL
Row 1, Column 0
SEVERAL DAYS
Row 1, Column 1
MORE THAN HALF THE DAYS
Row 1, Column 2
NEARLY EVERY DAY
Row 1, Column 3
NOT AT ALL
Row 2, Column 0
SEVERAL DAYS
Row 2, Column 1
MORE THAN HALF THE DAYS
Row 2, Column 2
NEARLY EVERY DAY
Row 2, Column 3
NOT AT ALL
Row 3, Column 0
SEVERAL DAYS
Row 3, Column 1
MORE THAN HALF THE DAYS
Row 3, Column 2
NEARLY EVERY DAY
Row 3, Column 3
NOT AT ALL
Row 4, Column 0
SEVERAL DAYS
Row 4, Column 1
MORE THAN HALF THE DAYS
Row 4, Column 2
NEARLY EVERY DAY
Row 4, Column 3
NOT AT ALL
Row 5, Column 0
SEVERAL DAYS
Row 5, Column 1
MORE THAN HALF THE DAYS
Row 5, Column 2
NEARLY EVERY DAY
Row 5, Column 3
NOT AT ALL
Row 6, Column 0
SEVERAL DAYS
Row 6, Column 1
MORE THAN HALF THE DAYS
Row 6, Column 2
NEARLY EVERY DAY
Row 6, Column 3
1
of 7
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7
GAD-7 Score Outcome
Interpretation for GAD-7 SCORE:
0-4
= Minimal to None
5-9
= Mild (monitor)
10-14
= Moderate (potential of clinically significant condition)
15+
= Severe (active treatment)
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