This is a summary of the assessment and can be done at the end. This section does NOT contain a video
| Clients Name: | DOB: | ||||
| Service: | UR: | ||||
| Mental health services assessment required? | No | Yes | |||
| Suicide/self-harm risk (please circle): | High | Moderate | Low | ||
| Date: | Screen completed by: | ||||
| Clinician use only Complete this section when all components of the PsyCheck have been administered. |
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| Summary | ||||
| Section 1 |
Past history of mental health problems | No | Yes | |
| Section 2 |
Suicide risk completed and action taken | No | Yes | |
| Section 3 | SRQ score | 0 | 1-4 | 5+ |
| Interpretation/score – SRQ | ||||
| Score of 0* on the SRQ |
No symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Re-screen using the PsyCheck Screening Tool after 4 weeks if indicated by past mental health questions or other information. Otherwise monitor as required. |
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| Score of 1–4* on the SRQ |
Some symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Give the first session of the PsyCheck Intervention and screen again in 4 weeks. |
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| Score of 5+* on the SRQ | Considerable symptoms of depression, anxiety and/or somatic complaints
indicated at this time. Action: Offer Sessions 1–4 of the PsyCheck Intervention. |
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| Re-screen using the PsyCheck Screening Tool at the conclusion of four sessions. | ||||
| If no improvement in scores evident after re-screening, consider referral. | ||||
| * Regardless of the client’s total score on the SRQ, consider intervention or referral if in significant distress. | ||||
| Show / Hide the correct answers. | ||||
