Mental Health Survey

Mental Health Survey

This survey is designed to help identify areas where you may need support and connect you to the right resources. Please answer the questions honestly.
General Information

Tell us more about yourself.
Name*

First NameLast Name
Birth Date*

DayMonthYear
Date
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Gender*
Location*

Street Address

Street Address Line 2

CountryState / Province

Postal / Zip CodeCity
Section 1: Emotional Well-Being
In the past two weeks, how often have you felt hopeless or down?*

NeverRarelySometimesOftenAlways
How often do you feel overwhelmed by emotions?*

NeverRarelySometimesOftenAlways
Have you experienced sudden mood swings recently?*

NeverRarelySometimesOftenAlways
Section 2: Physical and Mental Fatigue
How often do you feel excessively tired even after a full night's sleep?*

NeverRarelySometimesOftenAlways
Do you struggle to focus or concentrate on daily tasks?*

NeverRarelySometimesOftenAlways
Have you experienced significant changes in your sleep patterns (e.g., insomnia or oversleeping)?*

NeverRarelySometimesOftenAlways
Section 3: Social and Behavioural Patterns
How often do you withdraw from social interactions or avoid friends and family?*

NeverRarelySometimesOftenAlways
Have you noticed changes in your appetite (eating much more or less than usual)?*

NeverRarelySometimesOftenAlways
Do you engage in unhealthy coping mechanisms (e.g., substance use, overeating, etc.)?*

NeverRarelySometimesOftenAlways
How often do you feel inadequate or like a failure?*

NeverRarelySometimesOftenAlways
Have you had thoughts of self-harm or suicide in the past month?*

NeverRarelySometimesOftenAlways
Section 4: Self-Perception and Safety
How often do you feel life is meaningless or not worth living?*

NeverRarelySometimesOftenAlways
In the past two weeks, how often have you felt hopeless or down?*

NeverRarelySometimesOftenAlways
Do you have any pre-existing mental health conditions? If yes, please select all that apply*

NoneDepressionAnxiety Disorders (e.g., Generalized Anxiety Disorder, Panic Disorder)Bipolar DisorderPost-Traumatic Stress Disorder (PTSD)Obsessive-Compulsive Disorder (OCD)Attention-Deficit/Hyperactivity Disorder (ADHD)Other
please describe
Physical Health assessment
Height*
Height in inches
Weight*
Weight in lbs
Do you engage in regular physical activity or exercise?*

Yes, dailyYes, a few times a weekRarelyNever
Do you follow a balanced and nutritious diet?*

Yes, dailyYes, a few times a weekRarelyNever
How would you rate your daily energy level?*

1

2

3

4

5

1 is Worst, 5 is Best
Rate your overall stress level*

1

2

3

4

5

1 is Best, 5 is Worst
Do you need help?
Thank You! We will contact you shortly.
Preferred Contact method

Phone CallEmailPhone MessageOther
Anything you'd like to ask us?
Should be Empty:

Mental Health Survey

General Information

Section 1: Emotional Well-Being

Section 2: Physical and Mental Fatigue

Section 3: Social and Behavioural Patterns

Section 4: Self-Perception and Safety

Physical Health assessment