Mental Health Questionnaire
MENTAL HEALTH QUESTIONNAIRE
Maryland Healthy Kids Program
Date_________
Child¡¯s Name: _________________________________________ Date of Birth: ______________
Managed Care Organization: ________________________ Child¡¯s Medicaid #: ______________
Ages 13 ¨C 20 years
Check all answers that may apply. This form may be filled out by the patient, parent/guardian or health
care provider.
Do you have trouble paying attention? ¡¡¡..¡¡¡¡¡¡¡¡¡¡¡...
Yes
No
Do you often:
Feel distrustful of others? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Have strange thoughts? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Hear voices? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡...
Have to do things the same way or keep repeating them? .¡¡¡
Yes
Yes
Yes
Yes
No
No
No
No
Do you have problems at school with:
Behavior? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Grades? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Skipping classes? ¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Yes
Yes
Yes
No
No
No
Do you worry about your:
Eating? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Sleep? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.
Weight? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Yes
Yes
Yes
No
No
No
Do you have trouble making or keeping friends? ...¡¡¡¡¡¡¡¡¡¡.
Yes
No
Do you often feel:
Sad? ¡¡¡¡¡¡¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Angry? ¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Nervous or afraid? ¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Yes
Yes
Yes
No
No
No
Have you thought about or done any of the following:
Destroy property? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Hurt animals? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.
Set fire? .¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡...¡¡..
Listen to music with violent message? ¡¡¡¡¡¡¡¡¡.¡¡¡..
Use alcohol? .¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.
Use drugs? .¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Smoke cigarettes? ¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Sex without protection? ¡¡¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡..
Suicide attempt? ¡¡¡¡¡¡¡¡¡¡¡.¡¡¡¡¡¡.¡¡¡¡.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Continued on back
¡ú
MARYLAND HEALTHY KIDS PROGRAM
Maryland Department of Health and Mental Hygiene HealthChoice and
Acute Care Administration, Division of Children's Services
2014
MENTAL HEALTH QUESTIONNAIRE
Maryland Healthy Kids Program
Page Two
Is there a history of injuries, accidents? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Yes
No
If yes, please specify: _____________________________________________________
Is there any history of maltreatment or abuse? ¡¡¡¡¡¡¡¡¡¡¡¡
Yes
No
If yes, please specify: _____________________________________________________
Is there a recent stress on the family or child such as :
Birth of a child? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.
Yes
No
Moving? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.
Yes
No
Divorce or separation? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Yes
No
Death of a close relative? .¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..
Yes
No
Fired or laid off? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Yes
No
Legal problems? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡. Yes
No
Others (Please specify): ______________________________________________
Do you have other parenting concerns? ¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡
Yes
No
Please specify: __________________________________________________________
Provider: Give details of all Positive findings.
_______________________________________________
Provider¡¯s Signature
Provider¡¯s Phone: (__ __ __) /__ __ __ /__ __ __ __
_________________
Date
THIS FORM MAY BE USED FOR MENTAL HEALTH REFERRALS
Child Receiving Referral: ___________________________________________________
Child¡¯s Address: __________________________________________________________
Child¡¯s Phone: ___________________________________________________________
Referred to: Maryland Public Mental Health System: 1-800-888-1965_______________
Reason for Referral: _______________________________________________________
_______________________________________________________________________
MARYLAND HEALTHY KIDS PROGRAM
Maryland Department of Health and Mental Hygiene HealthChoice and
Acute Care Administration, Division of Children's Services
2014
................
................
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