Do you have signs and symptoms of a mental health problem? Please share with us any information (social, clinical, legal, administrative, etc.) that will help Dr. Minh and the health care team work with you.

The purpose of this tool is to improve the collaboration between you and the health care team. This in turn should improve the care offered, promote a real framework of holistic, personalized and early treatment/interventions to better lead your recovery. This is not a substitute for face-to-face meetings requested by the team and is not a comprehensive assessment of your psychiatric condition.

In this case, this form is used to prepare for the visio (zoom) meeting with Dr. Minh. http://visio.lequi-libre.ca

You must have a personalized code UIC (based on you RAMQ#) to be able to fill out this form beyond this introductory page.

**************** Instructions and warnings ****************

Information is essential in the assessment and treatment of your condition. We therefore ask you to take the time to complete this questionnaire to the best of your knowledge, keeping in mind that one of the most important pieces of information is the CHANGE in a mental state, a way of being, a way of thinking, lifestyle habits, moods, behaviors, etc. It is a matter of listing to the best of your knowledge what you have observed so far without making a formal assessment. This is not your task or within your competence. On the contrary, questioning yourself too much can lead to more undue concern and harm your ability to be resilient. This should be done by a professional. This is in no way a diagnostic tool or an evaluation of the urgency of the situation you are experiencing. You must use your judgment to determine whether it is necessary to call emergency services via #811 (health/social information) or #911 (police ambulance).

The use of this form is exclusively under your responsibility and you acknowledge that neither the author, nor any of its directors, employees or consultants can be held liable for any damages, direct or indirect, foreseeable or unforeseeable, and of any nature whatsoever, resulting from your use of the material published on this website, including the use of this questionnaire.

This form has been designed with GoogleForms tools that comply with HIPAA security standards. It is nevertheless transmitted via the Internet using protocols that are not necessarily totally secure. No confidentiality of information can be totally guaranteed for this reason. If you have any concerns, we therefore recommend that you do not disclose any information that could identify the person. This information may be obtained later through telephone/visual/personal communication if necessary. For more information about the security of this form: https://www.lequi-libre.ca/sécurité 

updated: 2020-07-27 (TNM)