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Patient Health Questionnaire — Modified for Teens

Heidrich Psychological Evaluations Center and Psychotherapy
5743 Corsa Ave. Ste 125. Westlake Village, CA. 91360
Brenda Heidrich | Ph.D Lic# Psy 29105 | Phone: 310-748-8393 | [email protected]

Please make sure you answer all required fields to submit this form.
If you do not answer all required fields then the form will not be sent.

Personal Information

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Name(Required)
Please enter a number from 0 to 99.
MM slash DD slash YYYY

Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things?(Required)
2. Feeling down, depressed, irritable or hopeless?(Required)
3. Trouble falling asleep, or staying asleep, or sleeping too much?(Required)
4. Feeling tired or having little energy?(Required)
5. Poor appetite, weight loss, or overeating?(Required)
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down?(Required)
7. Trouble concentrating on things like school work, reading, or watching TV?(Required)
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?(Required)
9. Thoughts that you would be better off dead or of hurting yourself in some way?(Required)

10. If you are experiencing any of the problems on this form, 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?(Required)
11. In the past year, have you felt depressed or sad most days, even if you felt OK sometimes?(Required)
12. Has there been a time in the past month when you have had serious thoughts about ending your life?(Required)
13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?(Required)
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Contact

Call us to schedule an appointment
Dr. Goodman: +1 -818-917-4524 
Dr. Heidrich: +1-310-748-8393 ,
or
send us an email and we will get back to you
as soon as possible.