Youth Mental Wellness & Safety Screening
Complete the youth details and answer the mental wellness, safety, and abuse questions using the provided response scales.
Youth Name
*
First Name
Last Name
Age
*
Date
*
-
Month
-
Day
Year
Date
Depression Screening
Felt sad or down
*
1 - Never
2 - Often
3 - Almost Always
Lost interest in activities
*
1 - Never
2 - Often
3 - Almost Always
Trouble sleeping or sleeping too much
*
1 - Never
2 - Often
3 - Almost Always
Feeling tired or low energy
*
1 - Never
2 - Often
3 - Almost Always
Feeling hopeless about the future
*
1 - Never
2 - Often
3 - Almost Always
Anxiety Screening
Feeling nervous or on edge
*
1 - Never
2 - Often
3 - Almost Always
Unable to stop worrying
*
1 - Never
2 - Often
3 - Almost Always
Trouble relaxing
*
1 - Never
2 - Often
3 - Almost Always
Easily annoyed or irritable
*
1 - Never
2 - Often
3 - Almost Always
Feeling afraid as if something awful might happen
*
1 - Never
2 - Often
3 - Almost Always
Suicide Risk Screening
Have you wished you were not alive?
*
Yes
No
Have you had thoughts of self-harm?
*
Yes
No
Have you made a plan to harm yourself?
*
Yes
No
Have you ever tried to harm yourself before?
*
Yes
No
SECTION 4: Abuse & Safety Indicators
Reverse scored: 1 = safe, 2 = sometimes feel unsafe, 3 = always feel unsafe
I feel safe at home.
*
1 = safe
2 = sometimes feel unsafe
3 = always feel unsafe
Someone has hurt my body.
*
1 = safe
2 = sometimes feel unsafe
3 = always feel unsafe
Someone has touched me in a way that made me uncomfortable.
*
1 = safe
2 = sometimes feel unsafe
3 = always feel unsafe
I am told to keep secrets that make me uncomfortable.
*
1 = safe
2 = sometimes feel unsafe
3 = always feel unsafe
I am scared to go home sometimes.
*
1 = safe
2 = sometimes feel unsafe
3 = always feel unsafe
I do not always have enough food or basic needs.
*
1 = safe
2 = sometimes feel unsafe
3 = always feel unsafe
Write anything else you feel is important to share
Submit Screening
Should be Empty: