Behavioral Health Assessment | Driscoll Health Plan

This short survey will only take a few minutes to complete and will help us monitor how you/your child(ren) are doing. All questions should be answered about the member of your family that you list below with behavioral health struggles. If you would like to complete forms for more than one family member, you will be able to at the end.

* = required

Name*

First Last

Date of Birth*

On a scale of 1 to 10, how would you rate your/your child’s level of overall health and well-being?*

1 - My health/well-being is great10 - My health/well-being is poor

How often have they been bothered by the following over the past 2 weeks?

Feeling nervous, anxious, or on edge*

Not at All
Several Days
More than half the days
Nearly every day

Not being able to stop or control worrying*

Not at All
Several Days
More than half the days
Nearly every day

Little interest or pleasure in doing things*

Not at All
Several Days
More than half the days
Nearly every day

Feeling down, depressed or hopeless*

Not at All
Several Days
More than half the days
Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way*

Not at All
Several Days
More than half the days
Nearly every day

Do you have medication to help with your mental health?*

Yes
No

Do you take the medication?*

Yes, I take it as prescribed
I take it most of the time
I take it when I feel bad
I don't take it

Would you like more information on different resources and support groups that are available to support you in managing your condition?*

Yes
No

Comments

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PHQ-2 Score

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GAD-2 Score

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Escalate

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MemberID