• Emotional Wellness Assessment

    This series of short forms will help your therapist understand more about you and your unique mental health profile. From this, she can get started on designing an individualized approach to most effectively meet your needs.

  • If you get started and find that you need to complete the form later, click "save" at the bottom, and you will be asked to enter your email. You'll be sent a link to complete it later if you want to do so on another device or browser.

  • Format: (000) 000-0000.

  • Your Mental Health History

  • Have you previously received any type of mental health services? Choose all that apply.*

  • What medications are you taking?

  • Medications

  • Overall Life Satisfaction

  • Please Rate Your Current Level Of Satisfaction in These Areas of Your Life:*
    Rows

  • Family Mental Health History

    Does your family have a history of any of the below?
  • *

  • Have you ever been professionally diagnosed with a mental health disorder (e.g. anxiety or depression)?

    (Please note a google self-diagnosis doesn't count ;)
    • I think I might have symptoms of: 

    • Do you suspect you may have symptoms of a disorder?  If so, please list below, and the therapist will evaluate you for any of these.

  • Common Situations That May Adversely Affect Your Mental Health

    • Recent Stressful Events  

  • Anxiety and Depression

  • Over the last 2 weeks, how often have you been bothered by the following symptoms:

     

    0 = Not at all

    1 = Several Days

    2 = More than Half the Days

    3 = Nearly Every Day

     

  • Feeling nervous, anxious or on edge
  • Not being able to stop or control worrying
  • Little interest or pleasure in doing things
  • Feeling down, depressed or hopeless
  • Trouble falling asleep, staying asleep, or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Feeling bad about yourself - or that you're a failure or have let yourself or your family down
  • Trouble concentrating on things, such as reading the newspaper or watching television
  • Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual
  • Thoughts that you would be better off dead or hurting yourself in some way
  • Have you ever drunk or used drugs more than you meant to?*
  • Have you felt you wanted or needed to cut down on your drinking or drug use?*

  • PTSD

  • Sometimes, things happen to people that are unusually frightening, horrible, or traumatic.

    For example:

    • a serious accident or fire
    • a physical or sexual assault or abuse
    • an earthquake or flood
    • a war
    • seeing someone be killed or seriously injured
    • having a loved one die through homicide or suicide

    In the past month, have you:

  • Had nightmares about the event(s) or thought about the event(s) when you did not want to?*
  • Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?*
  • Been constantly on guard, watchful, or easily startled*
  • Felt numb or detached from people, activities, or your surroundings?*
  • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?*

  • Risk of Self Harm

  • In the past few weeks, have you wished you were dead or wish that you could go to sleep and not wake up?*
  • In the past few weeks, have you felt that you or your family would be better off if you were dead?*
  • In the past few weeks, have you been having thoughts about killing yourself?*
  • In the past few weeks have you experienced any of the following?

  • NATIONAL SUICIDE PREVENTION HELPLINE:  1-800-273-8255

  • DateTime

  • Phew!

    With all that info, your therapist will be able to start working to develop your personalized treatment approach.
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