Date

Name

Gender

• Male

• Female

Email

Phone Number

Have you experienced the following in the past two weeks?

Select all that apply:

• Feeling down

• Depressed

• Hopeless

• Anxious

• Trouble sleeping/Sleeping too much

• Thoughts of self-harm

• Difficulty concentrating on tasks

• Changes in appetite

Do you feel overwhelmed by stress?

On a scale of 1 to 10, how would you rate your overall mental health?

Do you have a support system you can turn to when needed?

Are there any specific concerns or issues you'd like to share?