MHE Summary Template

[text name="variable_1" default="Name"] a [select name="variable_1" value="16|17|18|19|20|21|22|23|24|25|26"] year old [select name="variable_2" value="white|black|mixed race|African American|Asian American|Latina|Latino|Native American|Native Hawaiian|Pacific Islander|Alaska Native"] [select name="variable_3" value="male|female|non-binary individual|genderqueer individual|transgender individual|trans man|trans woman"] presented for assessment independently. [text name="variable_1"] reported that [select name="variable_4" value="he was|she was|they were"] seeking assessment for [textarea name="variable_1" default="Reason for seeking assessment"].  [text name="variable_1"] reported symptoms of 
[checklist name="variable_1" value="change in appetite,|decreased energy/fatigue|decreased interest in activities once enjoyed,|feeling withdrawn,|feeling unmotivated,|depression/sadness,|feelings of guilt, shame, & embarrassment,|feelings of hopelessness, helplessness, & worthlessness,|low self-esteem,|sleep disturbances,|excessive elevated or irritable mood,|increased activity or energy,|increased confidence (grandiosity),|pressured speech,|feeling nervous, anxious, or scared,|hoarding,|not able to stop worrying,|panic attacks,|phobias/unusual fears,|restless/muscle tension/easily fatigues,|social anxiety,|somatic complaints (stomach aches, headaches, muscle pain),|binging/purging/restricting intake,|body image distortion|eating nonfood substances (pica),|fear of weight loss or gain,|difficulty engaging in reciprocal social communication and social interaction,|restricted/repetitive behaviors and or interests (currently or in childhood),|sensory concerns,|hyperactivity,|impulsivity,|inattention,|actively defies/refuses to comply with rules and requests,|aggression,|angry/resentment,|arguing with authority figures,|blaming others,|cruelty to animals,|deliberately annoying others,|easily annoyed,|fire setting,|loses temper,|lying,|spiteful/vindictive,|violating rights of others,|hallucinations,|delusions,|compulsive spending,|gambling,|excessive gaming/internet/phone use,|hair pulling,|obsessions/compulsions,|skin picking,|hyperarousal,|re-experiencing,|emotional numbing,| trauma avoidance symptoms,|trauma cognitive symptoms"]. 

[Name] reports/denies [current/historical self-harm behaviors and suicidal ideation.] [Trauma history.]