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General Well-Being

On a scale of 1-10, how would you rate your overall mood in the past week?

Have you felt happy or content in the last seven days? (Yes/No/Sometimes)

How often do you feel tired or low-energy during the day? (Rarely/Sometimes/Often)

Stress and Anxiety

How often do you feel stressed or overwhelmed?

Have you experienced any physical symptoms of stress (e.g., headaches, stomachaches)?

What are your most common worries or stressors? (Open-ended)

Social Relationships

Do you feel connected to your friends or family?

How comfortable are you sharing your feelings with others?

Emotional Health

In the past month, have you had thoughts of sadness or hopelessness?

Do you feel like your emotions are out of control at times?

Coping Mechanisms

When you feel upset, what do you usually do?

Talk to someone Distract myself Cry Nothing

Are there activities that make you feel better when you're feeling low? (Open-ended)

Sleep and Routine

How many hours do you typically sleep each night?

Do you have trouble falling or staying asleep?

Any Note

Sunday Close

Saturday Close

Monday 2:00 PM to 9:00 PM

Tues Day 2:00 PM to 9:00 PM

Wednesday 2:00 PM to 9:00 PM

Thursday 2:00 PM to 9:00 PM

Friday 2:00 PM to 9:00 PM