At-Home Mental Health Assessment Questionnaire
Complete this self-assessment to reflect on your recent mental health and well-being. This questionnaire is for personal insight and is not a substitute for professional care.
Over 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
Over the past two weeks, how often have you felt nervous, anxious, or on edge?
*
Not at all
Several days
More than half the days
Nearly every day
How would you rate your sleep quality in the past two weeks?
*
1
2
3
4
5
How much have your mental health symptoms interfered with your daily activities (work, school, home) in the past two weeks?
*
Not at all
A little
Somewhat
A lot
In the past two weeks, how often have you felt able to cope with everyday stress?
*
Always
Often
Sometimes
Rarely
Never
How often have you felt you had support from friends, family, or others when needed?
*
Always
Often
Sometimes
Rarely
Never
In the past two weeks, have you had thoughts of self-harm or that you would be better off not here?
*
No, never
Yes, rarely
Yes, sometimes
Yes, frequently
Please indicate how often you have experienced the following in the past two weeks:
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
1
2
3
4
Trouble relaxing
5
6
7
8
Feeling tired or having little energy
9
10
11
12
Trouble concentrating
13
14
15
16
Would you like to be provided with additional resources or support options?
*
No
Yes, information about mental health resources
Yes, information about crisis support
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