Solace Mindcare | Mental Health Survey

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

This evaluation does not replace a clinical consultation, and is meant to support therapy. Everything shared in this evaluation remains confidential in terms of POPIA.
Over the last 2 weeks, how often have you been bothered by any of the following problems?

Please note, all the fields are required.

	Not at all	[A] Several days	[B] More than half the days	[C] Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3.Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Scoring
Total column [A] x 1 point =   Enter total
Total Column [B] x 2 points = Enter total
Total column [C] x 3 points =   Enter total
Add all points =  Enter TOTAL
Understanding Your Score.

Your responses give a glimpse into how you’ve been feeling lately.
- A score below 10 suggests that your mood is generally balanced — keep doing the things that support your wellbeing.
- Scores between 10 and 14 point to mild symptoms of depression; gentle self-care, connection, and rest can make a real difference.
- Scores between 15 and 19 suggest moderate symptoms, and it may be a good time to talk with a mental health professional like a psychologist for extra support.
- A score of 20 or higher indicates more severe symptoms, and we encourage you to see a doctor — you don’t have to face this alone.
About Your Mental Health
1. Have you ever been diagnosed with a mental health condition by a professional (doctor, therapist, etc.) ?

YesNo
2. Have you ever received treatment/support for a mental health problem?

YesNo
3. Think about your mental health test. What are the main things contributing to your mental health concerns right now? Choose up to 3.

CoronavirusRacismRelationship problemsPast traumaCurrent events (news, politics, etc.)Loneliness or isolationGrief or loss of someone or somethingFinancial problemsOther
About Your Health
1. Do you currently have medical aid?

YesNo
2. Do you have any of the following general health conditions? Select all that apply.

Heart DiseaseDiabetesCancerArthritis or other chronic painCOPD or other lung conditionsMovement disordersHIV/AIDSOther
About You
Age Range
Gender
Race/Ethnicity
Which of the following populations describe you? Select all that apply.

Caregiver of someone living with emotional or physical illnessLGBTQ+StudentTrauma survivorNew or expecting motherHealthcare workerOther

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Scoring

About Your Mental Health

About Your Health

About You