Adolescent Mental Health Screening Form
Full Name
Date of Birth
Age
Gender
Male
Female
Other
1. Over the last 2 weeks, how often have you felt down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day
2. Over the last 2 weeks, how often have you had little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
3. Have you experienced increased anxiety or worry recently?
No
Yes
4. Do you have trouble sleeping or staying asleep?
No
Yes
5. Have you experienced changes in appetite or weight recently?
No
Yes
Who do you usually talk to when you are upset or stressed?
Additional Comments or Concerns