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Sample Mental Health Assessment Form

The sample mental health assessment form is meant to give you an idea of how a professionally designed mental health assessment form may look and serve as a guide. When you are concluding your mental health assessment form, always make sure that it has enough space for gathering all the information you will need about the patient’s mental state of mind.

Time to complete

2 minutes

Eligibility

The Sample Mental Health Assessment Form is open to any individual who is seeking assessment for mental health purposes.

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Questions for Sample Mental Health Assessment Form

1.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
2.

Little interest or pleasure in doing things 

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
3.

Trouble falling or staying asleep, or sleeping too much 

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
4.

Feeling tired or having little energy

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
5.

Poor appetite or overeating

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
6.

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
7.

Trouble concentrating on things, such as reading the newspaper or watching television

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
8.

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

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
9.

Thoughts that you would be better off dead or hurting yourself in some way

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
10.

Have you ever been diagnosed with a mental health condition by a professional (doctor, therapist, etc.)?

The answer should be a single choice:
  1. Yes
  2. No
11.

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

The answer should be a single choice:
  1. Yes
  2. No
12.

Select all the population you belong

The answer should be a multiple choice:
  1. Veteran or active-duty military
  2. Caregiver of someone living with emotional or physical illness
  3. LGBTQ+
  4. Trauma survivor
  5. New or expecting mother
  6. Healthcare worker
13.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
14.

Gender

The answer should be a single choice:
  1. Male
  2. Female
  3. Other
  4. Prefer not to say

Similar Ideas

  • The General Health Questionnaire (GHQ)
  • The Patient Health Questionnaire (PHQ)
  • The World Health Organization Quality of Life (WHOQOL)

Here are some FAQs and additional information
on Sample Mental Health Assessment Form

What is included in a Mental health assessment?

A mental health assessment often includes a physical examination. In addition, your doctor will look at your past medical history and the medicines you are currently taking. You will also be asked about any history of mental illness or mental disorders in your family.

What is a Mental Health Assessment?

Mental health assessments are conducted by psychiatrists or psychologists to determine a patient's mental well-being. Using Free Health Assessment Forms, the clinician can find out what symptoms the client experiences, their duration, and any factors that are relevant to their issue. This kind of assessment can be considered a screening process and can show the severity of symptoms, which can inform the clinician if the client is in the early or late stages of the problem.

How to get a Mental Health Assessment?

If you feel troubled, you can talk to a friend or a family member. When circumstances present a problem that seems difficult to solve, you should consult your local psychologist.

What are the five signs of mental illness?

Mental illness is characterized by long-lasting sadness or irritability, extreme mood swings, excessive fear, worry, anxiety, social withdrawal, and dramatic changes in eating or sleeping habits.

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The sample mental health assessment form is meant to give you an idea of how a professionally designed mental health assessment form may look and serve as a guide. When you are concluding your mental health assessment form, always make sure that it has enough space for gathering all the information you will need about the patient’s mental state of mind.
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