Behavioral Health Self-Assessment Questionnaire
Please complete this confidential self-assessment to reflect on your recent mental and emotional well-being.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
How often have you experienced the following feelings or behaviors in the past two weeks?
*
Rows
Never
Rarely
Sometimes
Often
Almost always
Feeling nervous, anxious, or on edge
1
2
3
4
5
Feeling down, depressed, or hopeless
6
7
8
9
10
Trouble relaxing
11
12
13
14
15
Difficulty sleeping
16
17
18
19
20
Loss of interest or pleasure in activities
21
22
23
24
25
Feeling tired or having little energy
26
27
28
29
30
How would you rate your overall mood during the past two weeks?
*
1
2
3
4
5
How often do you feel socially connected to others?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your ability to cope with daily stress?
*
Not at all
1
2
3
4
5
6
7
8
9
Very well
10
1 is Not at all, 10 is Very well
In the past two weeks, how often have you used any of the following to help manage stress? (Select all that apply)
*
Physical activity or exercise
Talking to friends or family
Mindfulness or meditation
Professional support (counselor, therapist, etc.)
None of the above
Other
Have you had any thoughts of self-harm or harming others in the past two weeks?
*
Yes
No
Please share anything else about your current mental or emotional well-being that you would like to mention (optional)
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