PHQ - 9 NEW Today's Date MM slash DD slash YYYY Name First Last Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check the box next to the number that best describes how often you have been bothered by these problems. Little interest or pleasure in doing things:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Feeling down, depressed, or hopeless:* 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 Feeling tired or having little energy:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Poor appetite or overeating:* 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 reading the newspaper or watching television:* 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 Total Score: Adding the Score of your responses How difficult have these problems been for you? Not at all difficult Somewhat difficult Very Difficult Extremely Difficult Email If you have an appointment with a medication provider, please indicate who (otherwise leave blank) Dr. Kefalas Angela Pellerito Dannielle Nelson Melanie Troumbly If you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.
