Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Mental Health Survey Form Template

Enhance well-being assessments with our mental health survey template.

Creating a safe space for mental health discussions can be tough, but our template makes it easier. This mental health survey form helps you gather insightful feedback from individuals, ensuring their voices are heard and valued. Use it for employee check-ins, student wellness assessments, or community health initiatives. With customizable questions, mobile-friendly accessibility, and a focus on patient well-being, you can efficiently collect vital data that promotes mental health awareness and support. Explore the template now to start understanding your audience's needs better.

Use this Template (FREE) Live Preview
I consent to take part in this survey.
Yes
No
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
If you prefer to self-describe your gender, please specify.
What is your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Overall, how have you felt about your mental wellbeing over the past two weeks?
Very unhappy
Unhappy
Neutral
Happy
Very happy
How would you rate your stress level over the past two weeks?
Very low
Low
Moderate
High
Very high
How easy or difficult has it been to cope with day-to-day stressors?
Very difficult
Difficult
Neutral
Easy
Very easy
How often have you felt down, depressed, or hopeless in the past two weeks?
Very rarely
Rarely
Sometimes
Often
Very often
How often have you had little interest or pleasure in doing things?
Very rarely
Rarely
Sometimes
Often
Very often
How often have you felt nervous, anxious, or on edge?
Very rarely
Rarely
Sometimes
Often
Very often
How often have you found it hard to stop or control worrying?
Very rarely
Rarely
Sometimes
Often
Very often
How satisfied are you with your sleep over the past two weeks?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
How often have you had difficulty concentrating?
Very rarely
Rarely
Sometimes
Often
Very often
How often do you drink alcohol?
Never
Rarely
Sometimes
Often
Always
Prefer not to say
How often have you used recreational drugs in the past three months?
Never
Once
Monthly
Weekly
Daily
Prefer not to say
How satisfied are you with your level of social connection?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Do you have someone you can talk to about your mental health?
Yes
No
Have you received mental health support (e.g., counseling, therapy, medication)?
Currently
In the past
Never
Prefer not to say
If you needed support, how likely are you to seek professional help in the next month?
0 Not at all likely
1
2
3
4
5 Extremely likely
What are your main barriers to seeking help? (Select all that apply)
In the past two weeks, have you had thoughts of harming yourself?
Yes
No
Prefer not to say
Do you feel safe at home?
Always
Often
Sometimes
Rarely
Never
Prefer not to say
My work or studies negatively impact my mental health.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Is there anything else you would like us to know?
Which topics would you like more support or resources on? (Select all that apply)
Please Specify:
Email (optional)
Date of completion
Would you like to receive mental health resources or follow-up information?
Yes
No
{"name":"I consent to take part in this survey.", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"I consent to take part in this survey., What is your age?, If you prefer to self-describe your gender, please specify.","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a mental health survey form with various questions and icons related to mental well-being

When to use this form

Use this form when you need a quick, private check-in on mood, stress, sleep, and safety. It fits primary care pre-visit screens, school counseling after an incident, employee assistance intakes, and telehealth follow-ups. Responses help you spot risk, set priorities, and track change across weeks. Pair it with the Psychology questionnaire form for deeper symptom mapping, or move to the Psychiatrist interview form when you need a structured clinical history. Send it after starting a new medication, after a crisis line call, or at 30-day program reviews. The outcome: clear next steps, from self-care tips to urgent evaluation or referral.

Must Ask Mental Health Survey Questions

  1. Over the past two weeks, how often have you felt down, depressed, or hopeless?

    This checks for core signs of depression that affect motivation and daily function. Consistent wording helps you compare results over time and choose between brief support, therapy, or medication review.

  2. Over the past two weeks, how often have you felt nervous, anxious, or on edge?

    This identifies anxiety levels that may disrupt sleep, focus, and relationships. Clear frequency options guide whether to offer coping tools or recommend counseling.

  3. How often have you had trouble sleeping, such as falling asleep, staying asleep, or sleeping too much?

    Sleep issues often drive mood and concentration problems. Tracking frequency points to next steps, from sleep hygiene coaching to medical evaluation.

  4. Have you had any thoughts of harming yourself or that you would be better off dead?

    A direct safety check is essential to catch urgent risk. Clear answers trigger the right response, including immediate support and a safety plan if needed.

  5. In the past month, have you had periods of high energy with little sleep, racing thoughts, or risky behavior?

    These signs can indicate mood elevation that needs targeted care. If you see positives here, follow up with the Young mania rating scale (ymrs) form to measure severity.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel