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Self-Assessment Form: Understanding Your Mental Well-Being

This self-assessment helps our certified therapist understand your mental health concerns and recommend the right path or services for you.

 

This assessment is designed to help us understand your mental health challenges and recommend the most effective path forward. Please answer each question honestly by selecting the option that best reflects your current experience. Your responses are confidential.

Therapy
Take the first step toward healing—our confidential self-assessment form is your gateway to personalized support and a brighter future.

1. Personal Information

Birthday
Day
Month
Year
Gender
Male
Female
Non-binary
Other
Prefer not to say
Multi-line address

2. Emotional Well-Being

1- How often do you feel overwhelmed or emotionally drained?
Rarely
Occasionally
Frequently
Almost always
2- Do you experience frequent mood swings or irritability?
No
Sometimes
Often
Very often
3- Do you struggle to find joy or interest in activities you used to enjoy?
Never
Rarely
Sometimes
Frequently

3. Physical Symptoms

4- How often do you experience difficulty sleeping (insomnia or oversleeping)?
Never
Occasionally
Often
Almost daily
5- Do you feel fatigued or low on energy even after resting?
No
Sometimes
Frequently
Almost always
6- Have you experienced any unexplained physical symptoms (headaches, stomach issues, etc.) linked to stress?
No
Rarely
Occasionally
Frequently

4. Thought Patterns

7- Do you find yourself struggling with constant worry or anxious thoughts?
Never
Rarely
Sometimes
Frequently
8- Do you experience negative or self-critical thoughts about yourself?
Never
Rarely
Sometimes
Frequently
9- Have you ever felt hopeless or had thoughts of self-harm? (If yes, please consider seeking immediate help.)
No
Occasionally
Often
Very often

5. Social and Relationship Patterns

10- Do you avoid social interactions due to feelings of stress or discomfort?
Never
Rarely
Sometimes
Frequently
11- Have you experienced conflicts or difficulty maintaining relationships recently?
No
Occasionally
Often
Very often
12- Do you feel supported and understood by those around you?
Yes, always
Sometimes
Rarely
Never

6. Work, Study, and Daily Functioning

13- Do you find it hard to focus or concentrate on tasks?
No
Occasionally
Often
Almost daily
14- Have you felt unmotivated or unable to perform at your usual level in work or studies?
No
Occasionally
Frequently
Almost always
15- How often do you feel stressed or overwhelmed by daily responsibilities?
Never
Occasionally
Frequently
Almost daily

7. Coping and Support Mechanisms

16- Do you use coping strategies like journaling, mindfulness, or exercise?
Always
Sometimes
Rarely
Never
17- Have you ever spoken to a mental health professional or counselor before?
Yes
No
18- Would you like to explore therapy or counseling for support?
Yes
Maybe
No

Post-Submission Process

Once your form is submitted, our therapist will review your responses and reach out with a personalized plan. This may include therapy recommendations, stress management techniques, or referral to specialized services if needed.
 

Important: If you are feeling unsafe or experiencing a crisis, please seek immediate help by contacting a local mental health hotline or emergency services.

Supportive Friend
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