Questionnaire template

Emotional Well-being and Safety Check-In

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Healthcare · Mental health assessment. All Healthcare templates

Thank you for completing this check-in. Your answers are confidential and help our team offer you the right support.
This is a non-diagnostic check-in, not an assessment or diagnosis. If you are in immediate danger, call your local emergency number now.
Over the past two weeks, how often have you felt low or depressed?

Choose one:
- Not at all
- On some days
- On most days
- Nearly every day
How often do you feel hopeless about what lies ahead?

Choose one:
- Never
- Rarely
- Sometimes
- Often
- Always

Over the past two weeks, how often have you had thoughts of hurting yourself or ending your life?

Choose one:
- Not at all
- Once or twice
- Several times
- Most days
Thank you for telling us. You do not have to manage this alone: please contact a doctor, a mental health professional or a crisis line today, and call emergency services if you might act on these thoughts.
Would you like a member of our team to get in touch with you?

Condition: Shown when thoughts of self-harm were reported

Choose one:
- Yes, today
- Yes, within the next few days
- No

Which of these feelings have you had often recently? Select all that apply.

Choose any that apply:
- Sadness
- Fear
- Anger
- Hopelessness
- Loneliness
- None of these
Is there anything else on your mind that you would like us to know?

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