Patient Health Questionnaire-9 (PHQ-9) Modified for Adolescents (PHQ-A)

Please complete the following form.

Please complete the details below and then click on Submit and we'll be in contact.

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First Name*

Last Name*

Phone Number*

Email Address*

Current Mental Health Provider*

Please enter, "none" if you don't have a current provider.

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom use “√” to on the number that best describes how you have been feeling.

1. Little interest or pleasure in doing things?*

2. Feeling down, depressed, or hopeless?*

3. Trouble falling or staying asleep, or sleeping too much?*

4. Feeling tired or having little energy?*

5. Poor appetite or overeating?*

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down?*

7. Trouble concentrating on things, such as reading the newspaper or watching television?*

8. 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?*

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

Using the numbers of your answers, please enter your total score.*

In the past year have you felt depressed or sad most days, even if you felt okay sometimes*

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Has there been a time in the past month when you have had serious thoughts about ending your life?*

Have you EVER in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?*

_{**If you have had thoughts that you would be better off dead or hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911}

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