COUNSELING AND CONSULTATION ASSOCIATES

CLIENT NAME: Last:___________________ First: _____________ or CASE NUMBER: __________________________ DATE: ___________________

Counselor’s Name: _____________________________ Counselor’s Phone Number: _________________ Counselor’s E-Mail: _______________________

Return this form to your counselor to receive a result that you both can use for further evaluation and/or a counseling plan. A screening test is not a substitute for a complete evaluation but it can help you learn if your symptoms are consistent with depression, bipolar disorder, an alcohol problem, an anxiety disorder or post-traumatic stress disorder and how to access help.

Instructions to Interviewer or Client:

Carefully reflect on the questions asked in each block. Circle those that apply to you TODAY or within the past SEVEN days. When finished, return this page to your counselor.

This program is designed for individuals who are aged 17 and above. What is your date of birth? (mm/dd/yyyy) _____ / _____ / _____________