Welcome to Medivive
We commend you for taking this important step toward improving your mental health. This survey will help us better understand your mental health needs and provide personalized care tailored to you. Remember, you are not alone in this journey. Your health is our priority, and we are here to support you every step of the way.
Privacy and Confidentiality Statement
Your responses to this survey will be kept confidential and secure. Medivive follows all applicable privacy laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). All information collected will only be used to assist in your care, and no information will be shared with third parties without your explicit written consent, except where required by law.
Consent for Data Use
By completing this survey, you are consenting to the collection and use of your information by Medivive for the purpose of providing mental health care and support. This information will be stored securely and accessed only by authorized healthcare providers involved in your care. You have the right to request a copy of your responses and withdraw your consent at any time by contacting our office.
- Signature: ___________________________
- Date: ___________________________
HIPAA Privacy Notice (US-Based)
Your Rights Under HIPAA:
Medivive complies with all applicable HIPAA regulations. Under HIPAA, you have the right to:
- Access and request copies of your medical records.
- Request corrections to your personal health information.
- Request a list of disclosures of your health information.
- File a complaint if you believe your privacy rights have been violated.
Emergency Intervention Clause
If, at any point, Medivive believes that there is an immediate risk to your safety or the safety of others, we may be required to intervene and share your information with emergency services. This will be done to ensure the safety of everyone involved and is in accordance with applicable law.
Crisis Disclosure
If you are experiencing a mental health emergency, please seek help immediately by calling 911 or a local crisis hotline. This survey is not intended to provide immediate crisis support. Your safety is our top priority.
Limitation of Liability Disclaimer
Medivive is not liable for any damages, loss, or injury arising from the use of this survey. This tool is designed to assist in mental health care and does not replace professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Consent to Obtain Medical Records
I authorize Medivive to obtain any necessary medical records related to my mental health, substance use, or treatment history from the following providers:
- Facility/Provider Name: ______________________________________
- Contact Information: ______________________________________
- Signature: ________________________________________
- Date: ________________________________________
- Have you been treated for any mental health, alcohol, or substance use concerns in the past?
Yes ☐ No ☐ - If yes, please provide the following details:
Name of Facility/Provider: ________________________________________
Contact Information: ________________________________________
Section 1: Personal Information
- We appreciate you sharing this information—it helps us understand you better!
- Full Name: __________________________________________
- Date of Birth: __________________________________________
- Gender: Male ☐ Female ☐ Non-Binary ☐ Prefer not to say ☐
- Marital/Relationship Status:
Married ☐ Dating ☐ Single ☐ Separated/Divorced ☐ - Living Situation:
Alone ☐ With Spouse/Partner ☐ With Family ☐ With Roommates ☐ - Children? Yes ☐ No ☐
If yes, how many and what are their ages? ____________________________ - Email: ____________________ | Phone Number: ____________________
Section 2: Primary Mental Health Concern
Your honesty here is crucial for us to provide you with the best support possible!
- Please describe your main mental health concern (e.g., depression, anxiety, mood swings): __________________________________________
- How long have you been experiencing these symptoms?__________________________________________
- How would you rate the severity of your symptoms on a scale from 1 to 10?
Mild ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ Severe ☐ 10 - How often do your symptoms affect your daily activities (work, relationships, personal responsibilities)?
Never ☐ Rarely ☐ Sometimes ☐ Often ☐ Always ☐ - Do you notice any patterns that trigger these symptoms?
Yes ☐ No ☐ - If yes, please describe: __________________________________________
Section 3: Emotional and Psychological Well-Being
It’s important to reflect on these feelings; we’re here to listen and help!
- Feeling nervous, anxious, or on edge
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐ - Little interest or pleasure in doing things you once enjoyed
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐ - Feeling sad, empty, or hopeless
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐ - Excessive worry or fear about various situations
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐ - Irritability, frustration, or outbursts of anger
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐ - Feeling guilt, shame, or worthlessness
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐ - Feeling overwhelmed or out of control
Not at all ☐ 1-2 Days ☐ Several Days ☐ Nearly Every Day ☐
Section 4: Relationships & Support Networks
Strong connections are vital for mental health; let’s explore yours!
- How would you describe the quality of your relationship with your spouse/partner?
Supportive ☐ Strained ☐ Distant ☐ Neutral ☐ Not Applicable ☐ - How would you describe your relationship with your children (if applicable)?
Close ☐ Strained ☐ Neutral ☐ Not Applicable ☐ - Do you feel emotionally supported by your partner or close family members?
Yes ☐ No ☐ Sometimes ☐ - How do you typically communicate about feelings or challenges with your spouse/partner?
Openly ☐ Rarely ☐ Never ☐ - Do you have close friends or a trusted support system outside your family for emotional help?
Yes ☐ No ☐ - How often do you reach out to your support network for emotional help?
Frequently ☐ Occasionally ☐ Rarely ☐ Never ☐ - How often do you feel isolated or alone?
Never ☐ Rarely ☐ Occasionally ☐ Frequently ☐ Always ☐ - If you feel isolated, what are the main reasons?
Lack of support ☐ Geographical distance ☐ Personal choice ☐ Other:______________ - Do you engage in social activities or hobbies that bring you joy or relaxation?
Frequently ☐ Sometimes ☐ Rarely ☐ Never ☐ - Are there hobbies or activities that you share with others that positively affect your mental health?
Yes ☐ No ☐ - Do you feel you have someone to turn to in case of a mental health crisis?
Yes ☐ No ☐ Sometimes ☐ - Do you have an emergency contact who is aware of your mental health needs?
Yes ☐ No ☐ - When conflicts arise in your relationships, how do you typically resolve them?
Talking it out ☐ Avoiding the issue ☐ Other: _______________
Section 5: Sleep Patterns
Getting a good night’s sleep is essential for mental health—let’s assess yours!
- How many hours of sleep do you get on average per night?
Less than 4 hours ☐ 4-6 hours ☐ 6-8 hours ☐ More than 8 hours ☐ - Do you have difficulty falling asleep or staying asleep?
Yes ☐ No ☐ Sometimes ☐ - Do you wake up frequently throughout the night?
Yes ☐ No ☐ - Do you feel rested when you wake up?
Yes ☐ No ☐ Sometimes ☐ - Do you have any recurring dreams or nightmares?
Yes ☐ No ☐
Section 6: Cognitive Functioning
Understanding how you think and process information is important—let’s dive in!
- Have you experienced difficulty concentrating or remembering details?
Yes ☐ No ☐ Sometimes ☐ - Do you feel that your thoughts are racing or that you struggle to slow them down?
Yes ☐ No ☐ Sometimes ☐ - Do you have difficulty making decisions or organizing tasks?
Yes ☐ No ☐ Sometimes ☐
Section 7: Stress & Coping
Identifying your coping mechanisms can be a vital part of your healing process!
- How would you rate your stress levels?
Low ☐ Moderate ☐ High ☐ Overwhelming ☐ - How do you typically cope with stress? (Check all that apply)
Exercise ☐ Talking to Friends/Family ☐ Meditation ☐ Substance Use ☐ Journaling ☐
Other: ____________________________ - Do you find it difficult to identify your emotions?
Yes ☐ No ☐ Sometimes ☐ - Have you ever used self-harm (cutting, burning, etc.) to cope?
Yes ☐ No ☐
Section 8: Substance Use
It’s important to be honest about your substance use; we’re here to support you!
- Do you use alcohol or substances to cope with stress or mental health symptoms?
Yes ☐ No ☐ - If yes, how often do you use them?
Daily ☐ Weekly ☐ Occasionally ☐ Rarely ☐ - Has anyone ever told you that you have a problem with alcohol or drugs?
Yes ☐ No ☐ - Have you ever had to drink or use drugs to start your day?
Yes ☐ No ☐ - Have you ever tried to quit using substances?
Yes ☐ No ☐ - Do you feel that your substance use is affecting your relationships or health?
Yes ☐ No ☐ - If you’ve been seen for alcohol or drug use previously, please provide the facility or practice information:
Name of Facility: ______________________________________
Contact Information: ____________________________________
Section 9: Trauma History
Discussing trauma can be challenging, but it’s a crucial step toward healing.
- Have you experienced any traumatic events in your past (physical, emotional, sexual)?
Yes ☐ No ☐ - Would you like to discuss these events with your provider?
Yes ☐ No ☐ - Have these events contributed to your current mental health concerns?
Yes ☐ No ☐
Section 10: Suicidal Thoughts and Safety
Your well-being is our priority—let’s address any thoughts of self-harm together.
- Have you had thoughts of harming yourself or others in the past month?
Yes ☐ No ☐ - Do you have a safety plan in place if these thoughts arise?
Yes ☐ No ☐ - Do you have a trusted person you can contact during a crisis?
Yes ☐ No ☐ - Do you feel you have adequate access to mental health support in case of an emergency?
Yes ☐ No ☐ - Do you have a written safety plan in place if you experience thoughts of self-harm?
Yes ☐ No ☐ - Would you like help in developing a safety plan?
Yes ☐ No ☐
Section 11: Physical Health & Wellness
Physical health is intertwined with mental health; let’s explore yours!
- How often do you engage in physical activity (e.g., walking, running, sports)?
Daily ☐ Weekly ☐ Occasionally ☐ Never ☐ - Do you have any chronic health conditions that affect your mental health?
Yes ☐ No ☐ If yes, please specify: _____________________ - Do you feel your physical health and mental health are connected?
Yes ☐ No ☐ Sometimes ☐
Section 12: Technology Use and Impact
Understanding your relationship with technology can help us support you better.
- How often do you use technology for entertainment or work (e.g., video games, social media)?
Daily ☐ Weekly ☐ Occasionally ☐ Rarely ☐ - Do you feel your use of social media affects your mood or self-esteem?
Positively ☐ Negatively ☐ No effect ☐
Section 13: Mindfulness & Self-Care
Practicing self-care is essential for mental well-being; let’s assess yours!
- Do you currently practice any mindfulness techniques (e.g., meditation, yoga, breathing exercises)?
Yes ☐ No ☐ - If yes, how often?
Daily ☐ Weekly ☐ Occasionally ☐ Rarely ☐ - Do you practice any self-care routines (e.g., exercise, journaling, hobbies)?
Yes ☐ No ☐ - If yes, please describe your routine:
Section 14: Personal Growth & Aspirations
Your goals are important, and we’re here to help you achieve them!
- What personal goals or aspirations are you currently working toward?
- Do you feel your mental health affects your ability to achieve these goals?
Yes ☐ No ☐ Sometimes ☐ - How can Medivive support you in reaching these goals?
Section 15: Family Mental Health History
Understanding your family history can help us provide better care for you.
- Do you have any family members who have been diagnosed with mental health disorders?
Yes ☐ No ☐ - If yes, please specify the relation and diagnosis: ____________________________
Section 16: Childhood & Developmental History
Reflecting on childhood can be important for your healing journey.
- Did you experience any significant challenges during childhood (e.g., family conflict, abuse)?
Yes ☐ No ☐ - Would you like to discuss these experiences with your provider?
Yes ☐ No ☐
Section 17: Employment & Financial Stress
Financial stress can weigh heavily on mental health—let’s talk about it.
- Are you currently employed?
Yes ☐ No ☐ - Do financial concerns affect your mental health?
Yes ☐ No ☐ - Do you feel secure in your current job situation?
Yes ☐ No ☐ Sometimes ☐
Section 18: Consent to Obtain Medical Records
I authorize Medivive to obtain any necessary medical records related to my mental health, substance use, or treatment history from the following providers:
- Facility/Provider Name: ______________________________________
- Contact Information: ______________________________________
- Signature: ________________________________________
- Date: ________________________________________
Have you been treated for any mental health, alcohol, or substance use concerns in the past?
Yes ☐ No ☐
If yes, please provide the following details: - Name of Facility/Provider: ________________________________________
- Contact Information: ________________________________________
Section 19: Crisis Resources & Emergency Contacts
In case of a crisis, please contact:
Thank You for Your Participation!
Thank you for taking the time to complete this survey as part of your onboarding process with Medivive. Your responses will help us understand your needs and prepare for your consultation. If you have any questions about the survey or your mental health, please make a note of them and review them with your provider during your consultation.
We look forward to supporting you on your journey to better mental health!
