Your Program Title

Fax # :

Re :

DOB :

Mental Health Screener® Report

Your patient was screened on 06/14/2000. The responses meet criteria that are consistent

Attention :

ID # : 40004

Depression -

Mild

The patient DOES meet criteria for the Program.

COPE is recommended for this patient.

Yes

Yes

No

Program Treatment Recommendation

Patient Self-Report Questions & Responses:

Has your doctor prescribed an antidepressant medication for you ?

Are you taking this antidepressant medication ?

Are you currently under the care of a therapist or psychiatrist ?

If you have any questions about this fax, please call 608-827-2444 .