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Virtual Frequency of Forms


Frequency of Administration for Clinical Visits

My Wellness Passport Forms:
Frequency of administration reference table

For Clinical Visits

First Visit

Subsequent Visit
( ≤ 7)

Subsequent Visit
(greater than 7 days)

Registration Form (Registration)*

-

-

Before and/or While Youth is Receiving Services

Start of Visit Form (START_VISIT)*

      •     Add provider of START_VISIT

Service Request Form (SERVICE_REQUEST)*

Virtual/Remote Only Information Page (YOUTH_VIRTUAL_INFO_SHEET)

Consent – Youth (CONSENT)

-

-

Reason for Visit (REASON_VISIT)

Demographic Survey – Youth (DEMO)

-

✔ (30+      days later)

Self-Rated Health (SRH)

-

Self-Rated Mental Health (SRMH)

-

Kessler Psychological Distress Scale-6 (K6) or
Kessler Psychological Distress Scale-6 past week (K6W)

-

-

-

✔ (30+      days later)

✔ (8-29      days later)

Global Appraisal of Individual Needs: Short Screener (GAIN-SSS) or
YWHO Substance Monitoring Form (YSMF)

-

-

-

✔ (30+      days later)

✔ (8-29      days later)

Generalized Anxiety Disorder Scale (GAD-7)

-

Patient Health Questionnaire (PHQ-9)

✔ (if item #9 was positive at a prior visit)

Columbia – Suicide Severity (C-SSRS)* ˖

✔ (if deemed necessary)

Outcome Rating Scale (ORS)

-

Goal-Based Outcomes (GBO)

After Youth Has Received Services

Session Rating Scale (SRS)

Satisfaction and Service Experience (SATISFACTION)

End of Visit Form (END_VISIT)*

*Form is Completed by Service Provider

˖ Only completed if youth identified suicide ideation in the PHQ-9, or anytime @ the discretion of the clinician

Note: At the discretion of the service provider, any tool can be administered less than 7 days, if helpful for service provision

*Examples of Clinical Visits would be primary care or mental health services

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