Wellness Survey

Wellness Survey
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Your Therapist*
Over the last two weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?*
Feeling down, depressed, or hopeless?*
Trouble falling or staying asleep, or sleeping too much?*
Feeling tired or having little energy?*
Poor appetite or overeating?*
Feeling bad about yourself - that you are a failure or have let yourself or your family down?*
Trouble concentrating on things, such as reading or streaming videos?*
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 of hurting yourself in some way?*

Signature
Name of Person Completing Survey*
Date of Survey*

MonthDayYear
Patient's Signature*

Clear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Guardian's Name
Date

MonthDayYear
Guardian's Signature

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Should be Empty:

Signature