Mental Health Check-In Survey
Please complete this survey to help us better understand your current mental and emotional well-being. Your responses are confidential.
Full Name (optional)
First Name
Last Name
Date of Check-In
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall mood in the past week?
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Please indicate how often you have experienced the following in the past week:
*
Rows
Never
Rarely
Sometimes
Often
Always
Felt anxious or worried
1
2
3
4
5
Felt sad or down
6
7
8
9
10
Had trouble sleeping
11
12
13
14
15
Felt overwhelmed
16
17
18
19
20
Felt hopeful about the future
21
22
23
24
25
How would you rate your current stress level?
*
1
2
3
4
5
What coping strategies have you used recently? (Select all that apply)
*
Talking to friends or family
Physical activity or exercise
Meditation or relaxation techniques
Creative activities (art, music, writing)
Seeking professional support
Other
How supported do you feel by those around you?
*
Very supported
Somewhat supported
Neutral
Not very supported
Not at all supported
How many hours of sleep do you get on average per night?
*
Would you like someone to follow up with you regarding your responses?
*
Yes, please contact me
No, I do not need follow-up
If you answered yes above, please provide your preferred contact method (email or phone).
Is there anything else you would like to share about your current mental health or well-being?
Submit Check-In
Should be Empty: