VA Medical Center - VA Behavioral Health Outpatient Clinic Intake Questionnaire - Mental Health Assessment

Sep 19, 2026

Upload by Violet

VA Medical Center Behavioral Health Outpatient Clinic intake questionnaire for veterans, introducing the clinic and explaining how responses support assessment of current needs, understanding of the reasons for seeking care, and recommendations for treatment. The form collects direct narrative input on what brings the veteran to the clinic and how staff can help. It also asks about frequency of depression, sleep problems, fatigue, appetite changes, self-worth, concentration, psychomotor changes, suicidal thoughts, functional difficulty, anxiety symptoms, and trauma-related experiences over the last month, plus prior diagnoses and psychiatric hospitalization history.

LanguageEnglish

CategoryForms

FormatPDF

Pages12

Reading Time4 min

AccessFree to download

General Mental Health Services

Behavioral Health Outpatient Clinic Introduction

Over the Last Month Symptom Frequency

Functional Difficulty From Symptoms

Trauma and Mental Health History

VA Medical Center 10535 Hospital Way, Mather, CA 95655 Community Living Center (CLC) 150 Muir Road, Martinez, CA 94553 VA Outpatient Clinics: 1601 Concord Ave. , Chico, CA 95928 5342 Dudley Avenue, McClellan, CA 95652 201 Walnut Avenue, Mare Island, CA 94592 150 Muir Road, Martinez, CA 94553 2221 Martin Luther King, Jr. Way, Oakland, CA 94612 351 Hartnell Avenue, Redding, CA 96002 VA Outpatient Clinics (continued): 103 Bodin Circle, Bldg. 778, Travis AFB, CA 94535 425 Plumas Boulevard, Yuba City, CA 95991 11985 Heritage Oak Pl, Ste 100, Auburn, CA 95603 101 East Oberlin Road, Yreka, CA 96097 Oakland Behavioral Health Clinic 525 21st Street, Oakland, CA 94612 Martinez Behavioral Health Clinic 150 Muir Road, Bldg. 24 Martinez, CA 94553 Mather Behavioral Health Clinic 10535 Hospital Way, Building 651 Mather, CA 95655 Telephone Care: 1-800-382-8387 Website: [www.northerncalifornia.va.gov/](www.northerncalifornia.va.gov/) GENERAL MENTAL HEALTH SERVICES Behavioral Health Outpatient Dear Veteran, Welcome to the VA Behavioral Health Outpatient Clinic. Please complete the following questionnaire. While you will be interviewed by a mental health specialist, answering these questions will help us to: • Better assess your current needs. • Understand the reasons you’ve chosen to seek mental health care. • Recommend different types of treatments to assist in your recovery. The following pages include questions that help us assess your mental health needs, but also take abroader perspective that includes your social and cultural history that help us understand you as a whole person. Please answer to the best of your ability and knowledge. Please talk directly with your mental health specialist about any questions that you do not know or understand, if you are unable to recall, or if you choose to decline to answer. Please explain what brings you to our clinic. How can we help you? ______________________________________________________________ ______________________ ____________________________________________________________________ ________________ __________________________________________________________________________ __________ OVER THE LAST MONTH, HOW OFTEN HAVE YOU BEEN BOTHERED BY THE FOLLOWING: (Please check the appropriate box) Little interest or pleasure in doing things: □ Not at all □ Several days □ More than half the days □ Nearly every day Feeling down, depressed, or hopeless: □ Not at all □ Several days □ More than half the days □ Nearly every day Trouble falling asleep, staying asleep, or sleeping too much: □ Not at all □ Several days □ More than half the days □ Nearly every day Feeling tired or having little energy: □ Not at all □ Several days □ More than half the days □ Nearly every day Poor appetite or over eating: □ Not at all □ Several days □ More than half the days □ Nearly every day Feeling bad about yourself; that you are a failure or that you have let yourself or your family down: □ Not at all □ Several days □ More than half the days □ Nearly every day Trouble concentrating on things, such as reading the newspaper or watching television: □ Not at all □ Several days □ More than half the days □ Nearly every day Moving or speaking so slowly that other people could notice or being so fidgety and restless that you have been moving around a lot more than usual: □ Not at all □ Several days □ More than half the days □ Nearly every day Thoughts that you would be better off dead, or of hurting yourself: □ Not at all □ Several days □ More than half the days □ Nearly every day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? □ Not difficult at all □ Somewhat difficult □ Very difficult □ Extremely difficult (Please check the appropriate box) Feeling nervous, anxious, or on edge: □ Not at all □ Several days □ More than ha

FAQs

What is the purpose of this questionnaire for the VA Behavioral Health Outpatient Clinic?

It helps the clinic assess current mental health needs, understand why you chose to seek care, and recommend treatment options to support recovery.

What symptom areas does the form ask about for the last month?

It covers depressed mood, sleep problems, low energy, appetite changes, self-worth, concentration issues, psychomotor changes, suicidal-related thoughts, and anxiety symptoms.

Does the questionnaire ask about trauma and prior mental health treatment?

Yes. It asks whether you experienced or witnessed life-threatening events and related past-month symptoms, and whether you have been diagnosed with a mental health condition or hospitalized for psychiatric reasons.

Sep 19, 2026

Upload by Violet