Does your loved one seem to be showing the first signs of relapse into psychosis or is he or she not doing well? Please share any information (social, clinical, legal, administrative, etc.) that will help the care team work with your loved one.

The goal of this tool is to improve communication and collaboration between the care team and the loved ones. This in turn should improve the care offered, promote a real framework of holistic, personalized and early care in order to achieve a better recovery. This does not replace the family meetings requested by the team and does not constitute a model for a comprehensive assessment of a psychiatric condition.

This form is based on the "Early Psychosis Symptom Screening Questionnaire for Families". We invite you to fill it out if you have not already done so. That more detailed questionnaire should help us better determine the clinical information relevant in our follow-up of your loved one.

You must have a personalized code UIC (derived from the RAMQ code of the person concerned) to be able to fill out this form beyond this introductory page.

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

Information is essential in the assessment and treatment of mental health. 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... The idea is to check off the items on the lists according to what you have observed so far without making a formal assessment which is not your responsibility. On the contrary, questioning a loved one in a clumsy way can raise more mistrust, harm your relationship with the person (which is essential now and in the future of care) and be detrimental to you and the person concerned. A formal assessment should only be done by a professional. This is in no way a diagnostic tool or an evaluation of the emergency of the situation you are experiencing with your loved one. You must use your judgment to determine whether it is necessary to call the emergency services via #811 (info-santé/info-social) 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. For more information about the security of this form: https://www.lequi-libre.ca/sécurité 

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.

updated: 2020-07-26 (TNM)