PHQ-A

Thank you for choosing Northland Counseling Center! Please take a few minutes to fill out our online registration for your teen. Please complete the form below along with the Minor Registration Form, Health Questionnaire, GAIN-SS, SDQ – Parent Form, SDQ Teen Form, Supervision Form & GAD 7. Thank you!

PHQ – 9 Modified for Adolescents (PHQ-A)-Adapted

Today's Date
MM slash DD slash YYYY
Email
Name
First Last
Who will you be seeing today?
- Dr. Kefalas
- Angela Pellerito
- Melanie Troumbly
Instructions: How often have you been bothered by each of the following symptoms during the past 7 days? For each symptom check the box that best describes how you have been feeling.
Feeling down, depressed, or hopeless?*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Little interest or pleasure in doing things:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Trouble falling or staying asleep, or sleeping too much:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Poor appetite, weightloss, or overeating:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Feeling tired or having little energy:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Feeling bad about yourself — or that you are a failure or have let yourself or your family down:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Trouble concentrating on things, such as school work, reading or watching TV.*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
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:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday
Thoughts that you would be better off dead or of hurting yourself in some way:*
- 0 Not at all
- 1 Several days
- 2 More than half the days
- 3 Nearly everyday

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Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.