Emotional Wellness Assessment

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.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Mental Health History
Have you previously received any type of mental health services? Choose all that apply.*
Are you currently taking any psychotropic medication?*

Name*

First NameLast Name
Family Mental Health History

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

Name*

First NameLast Name
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?*

YesNo
Have you felt you wanted or needed to cut down on your drinking or drug use?*

YesNo

Name*

First NameLast Name
Risk of Self Harm
Name

First NameLast Name
In the past few weeks, have you wished you were dead or wish that you could go to sleep and not wake up?*

YesNo
In the past few weeks, have you felt that you or your family would be better off if you were dead?*

YesNo
In the past few weeks, have you been having thoughts about killing yourself?*

YesNo
In the past few weeks have you experienced any of the following?
NATIONAL SUICIDE PREVENTION HELPLINE: 1-800-273-8255

I filled out the information to the best of my ability*
Name

First NameLast Name
DateTime
Phew!

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

Rows	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied	Not Applicable
Physical Health
Appetite
Sleeping Habits
Exercise
Emotional Wellbeing
Spiritual Wellbeing
Level of Physical Pain
Job
Financial Health
Friendships
Family Relationships
Marriage or Romantic Relationship

Your Mental Health History