Rural Community Mental Health Outreach Screening Form

Full Name

Age

Gender Female Male Other Prefer not to say

Address/Barangay

Contact Number

Are you experiencing any of the following? (check all that apply)

How long have these symptoms been present?

Do these symptoms affect daily activities (work, school, relationships, etc)? Not at all Sometimes Often Always

Do you have a support system (family, friends, etc)? Yes No

Have you had thoughts of self-harm or suicide? No Yes, within last 2 weeks Yes, but not recently

Previous history of mental health issues? No Yes

Current medical conditions or medications (if any)

Additional Remarks / Notes