Confidential Employee Mental Health Self-Evaluation
Basic Information
Name (optional)
Date
General Well-being
Describe your current emotional state
How would you rate your energy levels this week?
Very Low
Low
Average
Good
Excellent
Work
How stressed do you feel with your current workload?
Not at all
A little
Moderately
Very
Extremely
What accomplishments are you proud of this week?
What challenges did you face?
Self-care & Support
How are you taking care of yourself?
Would you benefit from additional support?
Yes
No
Not sure
Additional Comments