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Mental Health Screening Form - Free Healthcare Template | ZenBuild | ZenBuild

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Mental Health Screening Form

Screen patients for common mental health concerns including depression, anxiety, and stress using standardized self-report questions. Supports early identification and referral.

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Mental Health Screening Form

Please answer these questions honestly. Your responses are confidential and will help guide your care.

Patient Name*

Date*

Over the past 2 weeks, how often have you felt little interest or pleasure in doing things?*

Not at allSeveral daysMore than half the daysNearly every day

Over the past 2 weeks, how often have you felt down, depressed, or hopeless?*

Not at allSeveral daysMore than half the daysNearly every day

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

Not at allSeveral daysMore than half the daysNearly every day

How would you rate your overall stress level right now?*

LowModerateHighVery high

Are you currently receiving mental health treatment?

Yes — therapyYes — medicationYes — bothNo

Anything else you would like your provider to know?

Template Details

CategoryHealthcare

IndustryHealthcare

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healthcaremental healthdepressionanxietyscreening