Self Assesment Tool

Self-Assessment Form

This is a confidential questioner. You do not have to give your full name or address. However, we need a phone number so we can call you back to find the way to support you.

Please respond the following questions.

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1.Over the past 2 weeks - I have felt more tired than usual? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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2.Over the past 2 weeks - I have had trouble sleeping ?Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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3. Over the past 2 weeks - I have felt very worried? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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4. Over the past 2 weeks - I have felt agitated & anxious ? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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5. Over the past 2 weeks - I have felt sad & down? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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6. Over the past 2 weeks - I have felt hopeless? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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7. Over the past 2 weeks- I felt restless & could not sit still? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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8. Over the past 2 weeks - I have felt everything is an effort ? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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9. Over the past 2 weeks - I have felt lonely & isolated? Not at allSeveral daysMajority of the daysAll the time

Mental Health Assesment

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Select one or more factors that matter, in finding the mental health support we linked you to.

Religion

Culture

Sexual orientation

Language

Specialized suppor to your needs.

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Confirm Submission.

We will call you within two business days to discuss how we can link you up to the appropriate support.

What is the best time of day for us to call you.

Confirmation

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Mental Health Assessment