GLORIOUS BEHAVIORAL HEALTH – INTAKE FORM

1. CLIENT INFORMATION

2. EMERGENCY CONTACT

3. CURRENT PSYCHOTROPIC MEDICATIONS (List)

List medications and any known medication allergies.

Name	Dose	Frequency	Prescriber

4. PRESENTING CONCERNS

5. GOALS FOR TREATMENT

PHQ-9 – Patient Health Questionnaire (Depression)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

0 = Not at all • 1 = Several days • 2 = More than half the days • 3 = Nearly every day

Item	Score
1. Little interest or pleasure in doing things	0 1 2 3
2. Feeling down, depressed, or hopeless	0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much	0 1 2 3
4. Feeling tired or having little energy	0 1 2 3
5. Poor appetite or overeating	0 1 2 3
6. Feeling bad about yourself — or that you are a failure	0 1 2 3
7. Trouble concentrating on things, such as reading or watching TV	0 1 2 3
8. Moving or speaking slowly or being fidgety/restless	0 1 2 3

GAD-7 – Generalized Anxiety Disorder Scale

Over the last 2 weeks, how often have you been bothered by the following problems?

0 = Not at all • 1 = Several days • 2 = More than half the days • 3 = Nearly every day

Item	Score
1. Feeling nervous, anxious, or on edge	0 1 2 3
2. Not being able to stop or control worrying	0 1 2 3
3. Worrying too much about different things	0 1 2 3
4. Trouble relaxing	0 1 2 3
5. Being so restless that it's hard to sit still	0 1 2 3
6. Becoming easily annoyed or irritable	0 1 2 3
7. Feeling afraid as if something awful might happen	0 1 2 3

Client Signature

Type your name as your signature.

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