Mental Health Risk Evaluation Form
Full Name
Age
Gender
Female
Male
Non-binary
Other
Prefer not to say
Contact Information
Mental Health History
Have you previously been diagnosed with any mental health condition?
Yes
No
If yes, please specify
Are you currently taking any medication for mental health?
Yes
No
If yes, please specify
Risk Indicators
Have you noticed significant changes in mood or behavior recently?
Yes
No
How would you rate your current stress level?
Low
Moderate
High
Are you experiencing any sleep disturbances?
Yes
No
Do you feel you have a support system?
Yes
No
Unsure
Have you had thoughts of self-harm or suicide?
Yes
No
Please provide any additional concerns or information: