BCFS00496-UAB-Shelton-AdolescentDepression [Screening Form

Screening Form

Please complete the screening form below

First Name

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Last Name

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Phone Number

Email Address

Gender

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Male

Female

Date of Birth

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What city do you live in?

What state do you live in?

What category best describes you?

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Is your child between the ages of 11 to 19?

Yes

Has your child been diagnosed with Major Depressive Disorder (MDD)?

Yes

Has your child had any thoughts of harming him/herself or ending his/her life in the last 2 weeks?

Yes

In the last two weeks, has your child attempted to end his/her life and it required medical attention?

Yes

Has your child used hallucinogens (except for cannabis), methamphetamine, or cocaine in the last 2 weeks?

Yes

Has your child ever undergone chemotherapy?

Yes

Has your child received any of the following diagnoses:

Lifetime history of psychotic disorder

Alcohol or drug use disorder (except nicotine/caffeine) within the last month.

Bipolar disorder

Pervasive developmental disorder

Cognitive disorder

DSM-5 paranoid, schizoid, or schizotypal personality disorders (PDs)

Anorexia nervosa

My child has not been diagnosed with any of these

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