PHQ-A TEEN DEPRESSION SCREEN

Date: [Date]
Teen: [Name or ID; age in years, 11 to 17]
Visit: [Annual check-up, sports physical, acute visit, or follow-up of known depression]
Setting: [Clinic, school-based health center, or telehealth]

HOW IT WAS DONE
Form: [Paper, tablet, or portal; language of the form]
Completed by: [Teen alone, or read aloud by staff; interpreter if used]
Time alone with the teen: [Yes or no; who stepped out of the room]
Confidentiality explained: [What stays private, and that safety concerns are shared]

SCORE
Items 1 to 9: [Score for each item, 0 to 3]
Total: [0 to 27; cutoff used, 10 or 11]
Severity: [None or minimal, mild, moderate, moderately severe, or severe]
Past year, sad most days: [Yes or no]
Difficulty with school, home, or friends: [Not difficult at all, somewhat, very, or extremely difficult]

SAFETY QUESTIONS
Item 9: [Score 0 to 3]
Serious thoughts of ending their life, past month: [Yes or no]
Suicide attempt, ever: [Yes or no; when and how, if known]
Same-day assessment: [Who did it; ideation, plan, intent, self-harm, access to means, protective factors; or not needed]
Risk level: [Low, moderate, or high, with the reasoning]

TALKING WITH THE TEEN
In their own words: [What the teen said about mood, sleep, school, friends, and home]
Psychosocial history: [HEEADSSS findings that bear on mood, such as bullying, substance use, or conflict at home]
Other causes considered: [Substance use, thyroid, sleep, grief, trauma, past mania]
Impression: [Working diagnosis or screen result]

PARENT OR CAREGIVER
Involved: [Who, and what was shared with the teen's agreement]
Home safety steps: [Firearms locked or stored away, medicines locked up, who will check in]

PLAN
Decision: [Watch and rescreen, therapy, medication, or urgent mental health assessment]
Safety plan: [Written with the teen and given to them, or not needed]
Crisis contacts: [988 by call or text, and local services]
Follow-up: [Date, and when the PHQ-A will be repeated]

Clinician: [Name, credentials]