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I consent to engaging in telehealth with Nevertheless Psychiatric Services, LLC. I understand the nature, risks, benefits, and alternatives to telehealth services. I understand I may withdraw consent at any time. All sessions are confidential, except where disclosure is required by law. In case of emergency, I will call 911.

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GAD-7: Generalized Anxiety Disorder Screener

Question [0] Not at all [1] Several days [2] More than half the days [3] Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Total Score (0-21): 0

PHQ-9 Modified for Adolescents (PHQ-9-M)

Question [0] Not at all [1] Several days [2] More than half the days [3] Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, sad, blue, or hopeless
3. Trouble falling asleep, staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - feeling like a failure or letting others down
7. Trouble concentrating on schoolwork, reading, or watching TV
8. Moving or speaking slowly or being fidgety/restless
9. Thoughts that you would be better off dead or of hurting yourself
10. Feeling more irritable, grumpy, or easily annoyed than usual

Total Score (0-30): 0

Basic Safety Plan

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