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107 6th Ave SW, Ronan, MT 59864

St. Luke Hospital
(406) 676-4441

Nurse On Call 24/7
(406) 676-3737

Clinics
Ronan (406) 676-3600
St. Ignatius (406) 745-2781
Southshore (406) 883-2555
Ridgewater (406) 883-3737

107 6th Ave SW, Ronan, MT 59864

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Behavioral Health Forms

Behavioral Health Forms

If you would prefer to download these forms, fill them out, and bring them to your appointment, then please feel free to do so.

Social Needs Screening

Initials Only*
D.O.B*
Month
Day
Year
Housing
Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as part of a household?*
- Yes
- No
Think about the place you live. Do you have problems with any of the following?*
(check all that apply)
- Bug infestation
- Mold
- Lead paint or pipes
- Inadeguate heat
- Oven or stove not working
- No or not working smoke detectors
- Water leaks
- None of the above
Food
Within the past 12 months, you worried that your food would run out before you got money to buy more.*
- Often true
- Sometimes true
- Never true
Within the past 12 months, the food you bought just didn't last and you didn't have enough money to get more*
- Often true
- Sometimes true
- Never true
Transportation
Do you put off or neglect going to the doctor because of distance or transportation?*
- Yes
- No
Utilities
In the past 12 months electric, gas, oil, or water company threatened to shut off services in your home?*
- Yes
- No
- Already shut off
Child Care
Do problems getting child care make it difficult for you to work or study?*
- Yes
- No
Employment
Do you have a job?*
- Yes
- No
Education
Do you have a high school degree?*
- Yes
- No
Finances
How often does this describe you? I don't have enough money to pay my bills.*
- Never
- Rarely
- Sometimes
- Often
- Always
Personal Safety
How often does anyone, including family, physically hurt you?*
- Never
- Rarely
- Sometimes
- Fairly often
- Frequently
How often does anyone, including family, insult or talk down to you?*
- Never
- Rarely
- Sometimes
- Fairly often
- Frequently
How often does anyone, including family, threaten you with harm?*
- Never
- Rarely
- Sometimes
- Fairly often
- Frequently
How often does anyone, including family, scream or curse at you?*
- Never
- Rarely
- Sometimes
- Fairly often
- Frequently
Assistance
Would you like help with any of these needs?*
- Yes
- No
References
https://www.va.gov/HOMELESS/Universal_Screener_to_Identify_Veterans_ Experiencing_Housing_Instability_2014.pdf Nuruzzaman N, Broadwin M, Kourouma K, Olson DP. Making the social determinants of health a routine part of medical Care. J Health Care Poor Underserved. 2015;26(2):321-327. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26-e32. Cook JT, Frank DA, Casey PH, et al. A brief indicator of household energy security: associations with food security, child health, and child development in US infants and toddlers. Pediatrics. 2008;122(4):e867-e875. Children’sHealthWatch.Final:2013Children’sHealthwatchsurvey.http://www. childrenshealthwatch.org/methods/our-survey/. Accessed October 3, 2018. Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low- income children’s well-child care visits: the WE CARE project. Pediatrics. 2007;120(3):547-558. Aldana SG, Liljenquist W. Validity and reliability of a financial strain survey. J Financ Couns Plan. 1998;9(2):11-19. Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med. 1998;30(7):508-512.

Patient Health Questionnaire
If you already filled this questionnaire out with a provider, then you may skip to the next page Over the last 2 weeks, how often have you been bothered by any of the following problems?
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 or 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 overeating
- Not at all
- Several days
- More than half the days
- Nearly every day
Feeling bad about yourself - or that you are a failure or 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 have noticed. Or the opposite - being so figety or 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

Generalized Anxiety Disorder Questionnaire
If you have already filled out this questionnaire with a provider, then you may skip to the next page. Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
- Not at all
- Several days
- Over half the days
- Nearly every day
Not being able to stop or control worrying
- Not at all
- Several days
- Over half the days
- Nearly every day
Worrying too much about different things
- Not at all
- Several days
- Over half the days
- Nearly every day
Trouble relaxing
- Not at all
- Several days
- Over half the days
- Nearly every day
Being so restless that it's hard to sit still
- Not at all
- Several days
- Over half the days
- Nearly every day
Becoming easily annoyed or irritable
- Not at all
- Several days
- Over half the days
- Nearly every day
Feeling afraid as if something awful might happen
- Not at all
- Several days
- Over half the days
- Nearly every day
If you checked off any problems, how difficult have these 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

Alcohol & Substance Use Screening Questionnaire
If you have already completed this questionnaire with a provider, you may skip to the end and submit
Once a year, we ask all of our patients to complete this form on conditions that affect their health. Please help us provide you with the best medical care by answering the questions below.
In the past 3 months...
How often did you have a drink containing alcohol?
- Never
- Monthly or less
- 2-4 times a month
- 2-3 times a week
- 4+ times a week
How many drinks containing alcohol did you have on a typical day when you were drinking?
- Never
- 1-2 drinks
- 3 or 4 drinks
- 5 or 6 drinks
- 7,8 or 9 drinks
- 10 or more drinks
How often did you have 5 or more drinks on one occasion?
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
How often have you used marijuana?
- Never
- Not monthly
- Monthly
- Weekly
- Daily or almost daily
How often have you used an illegal drug or a prescription medication for non-medical reasons*?
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
*if a patient needs further explanation, "for example, for the feeling or experienced it caused."
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© 2019 St. Luke Community Healthcare. All rights are reserved.

© 2019 St. Luke Community Healthcare. All rights are reserved.

Providers
Clinics
Pay My Bill
Health Portal Enrollment
Employee Email
Price Transparency
Privacy Policy

© 2018 St. Luke's Community Healthcare. All rights are reserved.