Mental Health Screening Form

Mental Health Screening Form — Form Fields

This healthcare template includes 8 fields. Screen patients for common mental health concerns including depression, anxiety, and stress using standardized self-report questions. Supports early identification and referral. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date (text, required)
• Over the past 2 weeks, how often have you felt little interest or pleasure in doing things? (multiple choice, required) — options: Not at all, Several days, More than half the days, Nearly every day
• Over the past 2 weeks, how often have you felt down, depressed, or hopeless? (multiple choice, required) — options: Not at all, Several days, More than half the days, Nearly every day
• Over the past 2 weeks, how often have you felt nervous, anxious, or on edge? (multiple choice, required) — options: Not at all, Several days, More than half the days, Nearly every day
• How would you rate your overall stress level right now? (multiple choice, required) — options: Low, Moderate, High, Very high
• Are you currently receiving mental health treatment? (multiple choice, optional) — options: Yes — therapy, Yes — medication, Yes — both, No
• Anything else you would like your provider to know? (long text, optional)