Mental Health Assessment Tool

The Mental Health Assessment form is a brief and confidential tool designed to help you evaluate your current mental well-being. By answering a few straightforward questions, you can gain insight into your emotional state and overall mental health. This assessment will provide you with personalized resources and support options based on your responses. Your answers are safe with us and will only be used to guide you toward the help you may need. Take the first step toward understanding your mental health today!

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Name *

First

Last

Do you have any chronic illnesses? *

Are you currently on any medication? *

Little interest or pleasure in doing things *Not at allSeveral daysNearly everyday

family, Feeling Poor

Feeling down, depressed, or hopeless *Not at allSeveral daysNearly everyday

Trouble falling or staying asleep, or sleeping too much *Not at allSeveral daysNearly everyday

Feeling tired or having little energy *Not at allSeveral daysNearly everyday

Poor appetite or overeating *Not at allSeveral daysNearly everyday

Feeling bad about yourself *Not at allSeveral daysNearly everyday

Trouble concentrating on things *Not at allSeveral daysNearly everyday

Moving or speaking so slowly that other people could have noticed *Not at allSeveral daysNearly everyday

Thoughts that you would be better off dead or of hurting yourself in some way *Not at allSeveral daysNearly everyday

How would you rate your overall stress level on a scale of 1 to 10?

Selected Value: 0

Do you have a support system (friends, family, etc.)? *

• I consent to be contacted for a follow-up by a healthcare professional.

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