PHQ-9 Contact Information*Resolutions Professional Counseling, PLLC Tara Fleis, LPC tfleis@resolutionsprofessionalcounseling.com 906-282-3130 9885 State Hwy. M95, Republic, MI 49879 308 Cleveland Ave. Ste. 302, Ishpeming, MI 49849 Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth*Gender*Phone*May I leave a message for you at this number?*YesNoEmail Preferred forms of communication*TextPhoneEmailEmergency contact (name, number, relationship):*Over the last 2 weeks, how often have you been bothered: Little interest or pleasure in doing things*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Feeling down, depressed, or hopeless*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Trouble falling or staying asleep, or sleeping too much*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Feeling tired or having little energy*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Poor appetite or overeating*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Feeling bad about yourself — or that you are a failure or have let yourself or your family down*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Trouble concentrating on things, such as reading the newspaper or watching television*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: 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*Not at allSeveral daysMore than half the daysNearly every dayOver the last 2 weeks, how often have you been bothered: Thoughts that you would be better off dead or of hurting yourself in some way*Not at allSeveral daysMore than half the daysNearly every dayIf 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?*Not difficult at allSomewhat difficultVery difficultExtremely difficultI have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.* I Agree Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY