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Requested Illustration:

1. CLIENT HAS BEEN DIAGNOSED AS:
HAVING DEPRESSION
BEING MANIC DEPRESSIVE (BIPOLAR)

2. HAS THE CLIENT EVER ATTEMPTED SUICIDE? THAN BY ACCIDENT?
Yes No IF YES,
Month   Year
Month   Year

3. HAS THE CLIENT EVER BEEN HOSPITALIZED FOR DEPRESSION?
Yes No IF YES,
Month   Year
Month   Year

4. DURING THE PAST 12 MONTHS, HAS THE CLIENT MISSED WORK DUE TO DEPRESSION?
Yes No IF YES, PLEASE DETAIL AND LIST NUMBER OF OCCASIONS AND AMOUNT OF TIME MISSED:

5. IS THE CLIENT CURRENTLY TAKING MEDICATION FOR DEPRESSION?

6. IS THE CLIENT CURRENTLY SEEING OR HAS SEEN A MENTAL HEALTH THERAPIST? Please Choose Yes Not Currently No
Not Currently
No
Yes. IF YES, OR NOT CURRENTLY, PLEASE DETAIL HOW OFTEN, FOR HOW LONG, AND THE DATE OF THE LAST VISIT:

7. CLIENTS MARITAL STATUS: Please Choose Married Single Divorced Widowed

8. IS THE CLIENT CURRENTLY RECEIVING. OR IN THE PAST RECEIVED, DISABILITY BENEFITS DUE TO DEPRESSION OR OTHER DEPRESSION?
Yes No IF YES, PLEASE DETAIL START AND END DATES:
START: Month   Year
END: Month   Year
IS STILL GETTING BENEFITS

9. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
Yes No IF YES, PLEASE DETAIL

10. CLIENT'S OCCUPATION

11. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
Yes No IF YES, PLEASE DETAIL

12. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: