Mental Health Screening Questionnaire
Name
Age
Gender
Female
Male
Other
Prefer not to say
Contact Information
Screening Questions
In the past two weeks, have you often felt down, depressed, or hopeless?
Never
Sometimes
Often
Always
Have you lost interest or pleasure in doing things?
Never
Sometimes
Often
Always
Do you often feel nervous, anxious, or on edge?
Never
Sometimes
Often
Always
Do you have trouble falling or staying asleep?
Never
Sometimes
Often
Always
How would you rate your energy level?
Very Low
Low
Average
High
Have you had thoughts of self-harm?
No
Yes
Additional Comments