ASSESSMENT FORM
DEPRESSION NEEDS ASSESSMENT: Identifying Pain Points and Challenges
Please take this 5 minute survey to share your pain points and future topics you’d like to hear more about. Thanks in advance for helping to advocate for mental health.
Gender:
Female
Male
What Is Your Age?
1. What is your goal (s) related to depression?
Increase Energy
Improve concentration
Find effective medication
Learn new coping strategies
Improved motivation
Increase productivity
Decrease brain fog
Improve Mood
Finding a Therapist/Counselor
Other
2. What's your biggest FRUSTATION related to managing depression and why do you think that is?
3. What is your BIGGEST FEAR concerning depression?
4. What do you feel is preventing you from getting better from the depression?
5. What Limiting Beliefs (other fears) may be holding you back from healing from depression?
6. What outside factors are possibly keeping you from achieving success with managing the depression? (i.e. access to care, affordability, shortage of therapists, etc.)
Access to care
Shortage of mental health professionals
Lack of support from family/friends
Difficult situations/relationships
Affordability
Limited time/time constraints
Reluctance to seek care/fear of stigmatization
Other
7. What are your struggles or challenges related to depression? (i.e. medication not helping, side effects, finding a therapist, access to care, no insurance, etc.)
Access to care
Shortage of mental health professionals
Being consistent on my part
Lack of support from family/friends
Prescribed medication being ineffective
Lack of insurance
Affordability
Lack of motivation to do anything
Limited time/Time constraints
Reluctance to seek care/fear of stigmatization
Medication side effects
Funding a therapist that I connect with
Other
8. Aside from medication, what other supportive management modalities have you pursued for the depression ? Please select all that apply.
Therapy/counseling
Anger management techniques
Journaling
Spending time with family/friends
Exercising
Bible reading
Sunlight/sun lamp therapy
Practicing gratitude
Stress management techniques
Trauma work
Dietary changes
Reading self-help/motivational books
Prayer
Spending time in nature
Music therapy/singing
Affirmations
Other
9. Are any of the following situations possibly contributing to your depression? Please select all that apply.
Being in a difficult relationship
Unresolved trauma
Having a chronic or terminal illness
Being primary caregiver for a sick loved one
Dissatisfying job/work environment
Difficult home environment
Unmanageable responsibilities/overwhelm
Stress/overwhelm
10. What things have you tried to manage the depression, and why do you feel that those things were not enough?
11. What PERSONAL FEARS OR LIMITING BELIEFS may possibly be playing a role in achieving success in your depression management?
12. What would your life be like if the depression was resolved, or, what could you see yourself doing that you feel that you aren't able to accomplish now?
13. What do you feel is keeping you stuck from resolving the depression?
Are you satisfied with your life?
Very Satisfied
1
2
3
4
5
6
Very Dissatisfied
7
1 is Very Satisfied, 7 is Very Dissatisfied
Done
Should be Empty: