Employee Workplace Mental Health Screening Form
Personal Information
Full Name
Department
Position/Job Title
Date
Mental Health Screening Questions
1. How have you been feeling emotionally at work recently?
2. How would you rate your current level of work-related stress?
Low
Moderate
High
Very high
3. Have you been experiencing any difficulties with sleep?
No
Sometimes
Frequently
4. Do you find it difficult to concentrate or focus on tasks?
No
Sometimes
Frequently
5. Do you feel supported by your coworkers and management?
Always
Sometimes
Rarely
Never
6. Are there specific workplace factors affecting your mental health?
7. Have you noticed any changes in your mood, appetite, or behavior?
8. Would you be interested in speaking to a mental health professional?
Yes
No
Maybe
Additional Comments
Please provide any additional comments or concerns: