Mental Health Monitoring Form
Please answer the following questions to help us monitor your mental health status.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
On a scale of 1 to 10, how would you rate your current mood?
1
1
2
3
4
Best
5
1 is , 5 is Best
In the past two weeks, how often have you felt anxious or stressed?
Not at all
Several days
More than half the days
Nearly every day
In the past two weeks, how often have you felt down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Do you have any coping strategies or activities that help you manage stress? Please describe.
Would you like to be contacted by a mental health professional?
Yes
No
Submit
Should be Empty: