The Sample Mental Health Assessment Form is open to any individual who is seeking assessment for mental health purposes.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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 hurting yourself in some way
Have you ever been diagnosed with a mental health condition by a professional (doctor, therapist, etc.)?
Have you ever received treatment/support for a mental health problem?
Select all the population you belong