Pediatric Depression Symptom Assessment Form

The following symptoms apply to adults, teens, adolescents and children. Check all that apply:

___ General feeling of sadness or depression

___ Loss of interest in activities once enjoyed

___ Changes in weight (+/- five pounds in a month) or appetite

___ Changes in sleep (sleeping more than seven to nine hours a day or less than six hours per night)

___ Overall feelings of guilt

___ Trouble concentrating, remembering things or making decisions

___ Experiencing fatigue or loss of energy

___ Experiencing restlessness or decreased activity (noticed by others)

___ Feelings of hopelessness or worthlessness

___ Thoughts of suicide or death (immediate trigger to call Willowbrooke at Tanner at 770.836.9551)

The following symptoms more likely seen in children, adolescents and teens. Check all that apply:

___ Frequent vague, nonspecific physical complaints such as headaches, muscle aches, stomachaches or “tiredness”

___ Frequent absences from school or poor school performance

___ Talk about or efforts to run away from home

___ Outbursts of shouting, complaining, unexplained irritability or crying

___ Being bored

___ Lack of interest in playing with friends

___ Alcohol or substance abuse

___ Social isolation, poor communication

___ Increased irritability, anger or hostility

___ Reckless behavior

___ Difficulty with relationships

___ Total # of triggers (one per check mark)

Three to five triggers indicate a need for a free, confidential mental health assessment from Willowbrooke at Tanner in an effort for the patient to be more thoroughly screened by a mental health professional, who can find links to mental health treatment providers.

Five or more triggers indicate possible major depression, and an immediate need to be evaluated by a Willowbrooke at Tanner mental health professional, who can find links to mental health treatment providers.

Willowbrooke at Tanner assessors will evaluate the mental health needs of the patient, consider the level of care that is appropriate for the patient, research providers that accept the patient’s insurance source and make recommendations to an appropriate treatment provide. At times, Willowbrooke at Tanner may have a program available that would meet the patient’s needs-on an outpatient or inpatient basis. Assessment counselors will communicate with referring physicians to provide information regarding the patient’s needs and on-going care recommendations.