Mind Above Matter - Daily Check-In Please check-in with the below form. Full Name*1. Did you start any new medications or have a change in medications?*YesNoIf yes, what medications:*2. Do you have any physical complaints to report today?*YesNoIf yes, please explain:*3. Are you having any difficulties performing at work/school?*YesNoIf yes, please explain:*4. Are you experiencing any type of psychosis, (hearing or seeing anything unusual)?*YesNoIf yes, please explain:*5. Have you noticed a change in your mood within the last 24-72 hrs?*YesNoIf yes, please explain:*6. Did anything occur within the last 24-72 hrs that created NEW stress for you?*YesNoIf yes, please explain:*7. Have you experienced any type of trauma within the last 24-72 hrs?*YesNoIf yes, please explain:*Was this reported to the police/CPS?*YesNoIf yes, when?* MM DD YYYY What was the outcome of the report?*8. Have you self-harmed within the last 24-72 hrs?*YesNoLast occurrence of self-harm?*Type of self-harm?*Consequence of self-harming?*9. On a scale of 0 to 5, please rate your depression today.*0 – not at all depressed12345 – very depressed10. On a scale of 0 to 5, how bad are your thoughts of suicide today?*0 – no thoughts1 – some thought2 – some thought3 – desire to act on thoughts4 – desire to act on thoughts5 – plan and/or intentOn a scale of 0 to 5, how bad are your thoughts of homicide today?*0 – no thoughts1 – some thought2 – some thought3 – desire to act on thoughts4 – desire to act on thoughts5 – plan and/or intentDo you have a suicide plan, or is there a specific person you feel homicidal against? Please explain.11. On a scale of 0 to 5, please rate your anxiety today.*0 – not at all anxious12345 – very anxiousIf you are experiencing panic attacks, please specify frequency (#/day):12. How many meals did you eat yesterday?*Is this an increase or decrease in appetite?IncreaseDecrease13. Are you having any sleep difficulties (falling/staying asleep/waking up)?*YesNoHow many times did you wake during the night?*How many hours of sleep did you get last night?*14. Identify healthy coping skills you are currently practicing:15. What unhealthy coping skills are you currently practicing:16. Within the last 24 hours, have you had any Substance Use (Alcohol or Drug)?*YesNoLast used:*Frequency:*Dosage:*What substances?*17. Activities of Daily Living (ADLs): Any difficulty in your ability to perform the following activities? Bathing/Showering Preparing meals Cleaning/maintaining your house/room Personal hygiene Managing money Dressing (clean clothes) Telephone/transportation Not taking medications as prescribed Walking Toileting Grooming If yes, please explain:18. Who can you specifically talk with about your mental health needs? Who will be involved in your treatment?*19. What are you grateful for today?*20. Please identify one thing your would like to discuss, in group today:*Your Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.