Prospective Patient Screening Questionnaire

Full Name

Section 1

Safety & Risk

1. Have you had thoughts of harming yourself or ending your life in the past month?

Yes No

2. Have you ever attempted suicide or engaged in self-harm?

Yes No

3. Do you currently have thoughts of harming someone else?

Yes No

4. Have you ever been hospitalized for psychiatric reasons?

Yes No

5. Do you currently use alcohol or substances in a way that concerns you or others?

Yes No

Section 2

Emotional Regulation & Impulsivity

6. Do your moods shift rapidly or feel difficult to control?

Never Sometimes Often

7. Do you struggle with intense anger or difficulty managing frustration?

Never Sometimes Often

8. Do you act impulsively in ways you later regret (e.g., spending, relationships, substances)?

Never Sometimes Often

9. Do you ever feel empty or unsure of who you are?

Never Sometimes Often

Section 3

Relationships

10. Do you find your relationships tend to be intense or unstable?

Never Sometimes Often

11. Do you worry about people abandoning or leaving you?

Never Sometimes Often

12. Do you tend to quickly lose trust in others or feel people are against you?

Never Sometimes Often

13. Do conflicts with others escalate quickly or feel hard to resolve?

Never Sometimes Often

Section 4

Behavior Patterns

14. Do you have difficulty following treatment recommendations or maintaining consistency with care?

Yes No

15. Have you worked with multiple therapists or psychiatrists in a short period of time?

Yes No

16. Have you ever felt dissatisfied with most prior mental health providers?

Yes No

Section 5

Expectations & Fit

17. What are you hoping to get out of treatment?

18. Are you open to therapy in addition to medication if recommended?

Yes No

19. Are you able to attend regular follow-up appointments and communicate respectfully with staff?

Yes No

Additional Information

Optional

20. Is there anything about past treatment experiences that you feel is important for us to know?

Your responses are confidential and used only to determine whether TJohnMD Wellness is the right fit for your needs. If you are experiencing a mental health emergency, please call 988 or 911 immediately.