First Responder Mental Health Status Screening Form
Full Name
Date
Role (e.g. EMT, Firefighter, Police Officer)
Shift/Unit
Current Mental Health Status
Overall Mood
Stable
Anxious
Depressed
Irritable
Other
Current Level of Stress
Low
Moderate
High
Overwhelmed
Sleep Quality
Good
Fair
Poor
Appetite
Normal
Increased
Decreased
Energy Level
Normal
Low
High
Recent Experiences
Have you experienced any particularly challenging calls/incidents recently?
Are you receiving adequate support from your team/organization?
Yes
No
How are you coping with work-related stress?
Would you like to speak to someone about your mental health?
Yes
No
Maybe
Additional Comments
Anything else you’d like to share?