Mental Health Check-Up

1

Name

First Name

Last Name

2

Email* This field is required.Don't worry, we will never sell your information and will only contact you if you request us to

example@example.com

3

Little interest or pleasure in doing things* This field is required.

Not at all

Several days

More than half the days

Nearly every day

4

Feeling down, depressed or hopeless* This field is required.

Not at all

Several days

More than half the days

Nearly every day

5

Trouble falling or staying asleep, or sleeping too much* This field is required.

Not at all

Several days

More than half the days

Nearly every day

6

Feeling tired or having little energy* This field is required.

Not at all

Several days

More than half the days

Nearly every day

7

Poor appetite or overeating* This field is required.

Not at all

Several days

More than half the days

Nearly every day

8

Feeling bad about yourself - or that you are a failure or have let yourself or your family down* This field is required.

Not at all

Several days

More than half the days

Nearly every day

9

Trouble concentrating on things, such as reading the newspaper or watching television* This field is required.

Not at all

Several days

More than half the days

Nearly every day

10

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* This field is required.

Not at all

Several days

More than half the days

Nearly every day

11

Thoughts that you would be better off dead, or of hurting yourself in some way* This field is required.

Not at all

Several days

More than half the days

Nearly every day

12

PHQ-9 Score

13

Minimal depression
Your responses do not currently suggest significant symptoms of depression. If concerns arise in the future, consider reaching out to a healthcare or mental health provider for support.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

14

Mild depression

Your responses suggest mild symptoms of depression. Monitoring symptoms and reaching out to a mental health provider may be helpful, especially if symptoms persist or worsen.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

15

Moderate depression

Your responses suggest moderate symptoms of depression.

We strongly encourage you to reach out to a licensed mental health provider to discuss support and treatment options.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

16

Moderately Severe Depression

Your responses suggest moderately severe symptoms of depression.

Prompt follow-up with a mental health provider is strongly recommended to ensure appropriate care and support.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

17

Severe Depression

Your responses indicate severe symptoms of depression. We strongly urge you to seek professional mental health support as soon as possible.

Want to schedule an appointment with a counselor?

Click HERE

If you are experiencing thoughts of harming yourself or feel unsafe, please seek immediate help by calling or texting 988 (Suicide & Crisis Lifeline) or going to the nearest emergency room.

This screening tool is not a diagnostic instrument.

18

The following questions will help us better understand your current anxiety levels and how they may be affecting you.

Over the past two weeks, how often have you been bothered by the following problems related to anxiety?

19

Feeling nervous, anxious, or on edge.

Not at all

Several days

More than half the days

Nearly every day

20

Not being able to stop or control worrying.

Not at all

Several days

More than half the days

Nearly every day

21

Worrying too much about different things.

Not at all

Several days

More than half the days

Nearly every day

22

Trouble relaxing.

Not at all

Several days

More than half the days

Nearly every day

23

Being so restless that it's hard to sit still.

Not at all

Several days

More than half the days

Nearly every day

24

Becoming easily annoyed or irritable.

Not at all

Several days

More than half the days

Nearly every day

25

Feeling afraid as if something awful might happen.

Not at all

Several days

More than half the days

Nearly every day

26

GAD-7 Score

27

Minimal Anxiety

Symptoms are within the typical range. Continue monitoring and practiving self-care.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

28

Mild Anxiety

You may be experiencing some anxiety symptoms. Consider stress-management strategies or discussing concerns with a healthcare provider if symptoms persist.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

29

Moderate Anxiety

Anxiety symptoms may be impacting daily functioning. Reaching out to a mental health professional is recommended.

Want to schedule an appointment with a counselor?

Click HERE

This screening tool is not a diagnostic instrument. If you are experiencing suicidal thoughts or emotional distress, please contact 988 (Suicide & Crisis Lifeline) or seek emergency care.

30

Severe Anxiety

Your responses indicate severe symptoms of anxiety. We strongly urge you to seek professional mental health support as soon as possible.

Want to schedule an appointment with a counselor?

Click HERE

If you are experiencing thoughts of harming yourself or feel unsafe, please seek immediate help by calling or texting 988 (Suicide & Crisis Lifeline) or going to the nearest emergency room.

This screening tool is not a diagnostic instrument.

31

Would you like to schedule an appointment with a Mental Health Provider?

YESNO

32

Please fill out this form and our Admin staff will contact you soon

HERE

or visit www.risinghope.com

33

Thank you for filling out our Mental Health Checklist!

www.risinghope.com