Psychological Distress Screening Survey
Please complete this survey to help assess your current level of psychological distress. Your responses are confidential and will be used for screening purposes only.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Email Address
*
example@example.com
In the past two weeks, how often have you felt nervous or anxious?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
In the past two weeks, how often have you felt down, depressed, or hopeless?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
In the past two weeks, how often have you experienced difficulty sleeping or staying asleep?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Please indicate how much the following issues have bothered you in the past two weeks:
*
Rows
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling tense or wound up
1
2
3
4
5
Trouble relaxing
6
7
8
9
10
Loss of interest in activities
11
12
13
14
15
Trouble concentrating
16
17
18
19
20
Withdrawing from social contact
21
22
23
24
25
How would you rate your overall level of psychological distress at this time?
*
1
2
3
4
5
Have you ever sought professional help for psychological distress?
*
Yes
No
Is there anything else you would like to share regarding your mental health or emotional well-being? (Optional)
Submit Survey
Should be Empty: