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Not feeling your best? you're not alone.
Please answer a few questions so that we can match you to the right therapist/counsellor.
Your answers will be kept confidential, and only used to make sure we provide the right care for you.
Hi, What's your name?
Before we get started, how are you feeling today?
Happy
Worried
Stressed
Relaxed
Sad
Angry
Not Sure
Congratulations on taking your step towards mental health care!
Please answer the upcoming questions as honestly as possible.
We're here to help you.
Think about the past couple weeks. Have you felt any of these?
Stressed or burned out
Problems with sleep - trouble falling or staying asleep , or sleeping too much
Nervous, anxious, or on edge
Lonely
Little interest or pleasure in doing things
Down, depressed or hopeless
More irritable than usual
Trouble focusing and motivating
In the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly everyday
in the last 2 weeks, how often have you been bothered by trouble falling or staying asleep, or sleeping too much?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by feeling tired or having little energy?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by poor appetite or overeating?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by 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?
Not at all
Several days
More than half the days
Nearly everyday
In the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or hurting yourself in some way?
Not at all
Several days
More than half the days
Nearly everyday
How difficult have these feelings made it for you to do your work, take care of things at home, or get along with others?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
What treatment are you most interested in?
Talk Therapy
Medication & Psychiatry
Not Sure
How old are you?
Where can we reach you
What's your email ID?
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