Mendelson Kornblum Physical Therapy

Mendelson Kornblum Physical Therapy

Short Form Depression Screening Questionnaire

Please check the boxes that apply to you in the last few weeks.
I am unable to do the things I used to do
I feel hopeless about the future
I cannot make decisions
I feel sluggish or restless
I am gaining or losing weight
I am tired for no reason
I am sleeping to much, or too little
I feel unhappy
I become irritable or anxious
I think about dying or suicide

Mendelson Kornblum Physical Therapy has a Social-Worker-Counselor on staff to speak with you about the questions listed above. She can also provide information about community resources to help you deal with your physical or psychological concerns.

Would you like the Social Worker-Counselor to contact you at this time?
Yes No

Would you like information about the Social Work-Counseling Services available at this site?
Yes No

Do not write below this line

Score: _______________/_______________
Referred to Social Worker-Counselor for possible intervention?
Yes No

Reviewed by Therapist: ______________________________________Date:__________

Social Worker-Counselor: ______________________________________Date:__________

Comments: ________________________________________________________________