Mental Health Self-Assessment Form
Full Name
Email Address
Age
Gender
Female
Male
Non-binary
Other
Prefer not to say
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Additional Information
Are there any other concerns you would like to mention?