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Mental Health Check-in Form

I. General Well-being and Mood

How would you rate your overall well-being today?

How would you describe your mood today?

Have you noticed any significant changes in your mood over the past few days, and what are they?

How much sleep did you get last night?

How would you rate your energy levels today?

How hydrated have you been today?

II. Emotional State

Actionable Item

Tick if Yes

Notes

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B
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1
Are you feeling any feelings of sadness or hopelessness?
 
2
Are you experiencing any feelings of anxiety or worry?
 
3
Are you feeling overwhelmed or stressed?
 
4
Have you felt irritable or angry recently?
 
5
Are you experiencing feelings of loneliness or isolation?
 
6
Have you felt any feelings of joy or contentment today?
 
7
Have you had any panic attacks, or felt close to having one, recently?
 

III. Physical Health

Actionable Item

Tick if Yes

Notes

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B
C
1
Have you experienced any changes in your appetite?
 
2
Have you experienced any changes in your sleep patterns?
 
3
Have you had any headaches or other physical symptoms related to stress?
 
4
Have you been experiencing any unexplained aches or pains?
 

IV. Coping and Support

What activities have you engaged in today to support your mental well-being? (e.g., exercise, meditation, hobbies)

Have you connected with any friends, family, or support systems recently?

Have you used any coping mechanisms today, and which ones? (e.g., deep breathing, grounding techniques)

Do you feel you have adequate support available to you?

Is there anything that is currently making you feel supported, and what is it?

Is there anything that is currently making you feel unsupported, and what is it?

V. Thoughts and Cognition

Actionable Item

Tick if Yes

Notes

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B
C
1
Have you had any negative or intrusive thoughts today?
 
2
Are you finding it difficult to concentrate or focus?
 
3
Are you experiencing any feelings of self-doubt or low self-esteem?
 

VI. Work/School/Daily Life

Actionable Item

Tick if Yes

Notes

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1
Are you experiencing any difficulties at work or school?
 
2
Are you finding it difficult to manage daily tasks?
 
3
Are you experiencing any relationship difficulties?
 

How are you managing your workload or responsibilities?

VII. Additional Information

Is there anything else you would like to share about your mental health today, and what is it?

What is one thing you are grateful for today?

What is one thing you can do to improve your well-being today?

What is one thing that has been difficult today?

Form Template Instructions

Please remove Form Template Instructions before publishing this form

 

1. Individual Self-Awareness:

  • Tracking Patterns: Regular use allows individuals to identify patterns in their mood, energy levels, and coping mechanisms. They can see how certain activities, stressors, or life events affect their mental health over time.
  • Identifying Triggers: By logging their experiences, individuals can pinpoint specific triggers that lead to negative emotions or behaviors.
  • Recognizing Early Warning Signs: Consistent check-ins can help individuals recognize early signs of mental health decline, allowing them to seek support before issues escalate.
  • Promoting Self-Reflection: The act of completing the form encourages introspection and self-awareness, which are essential for mental well-being.

2. Providing Data for Support and Intervention:

Healthcare Professionals:

  • The form can provide valuable data for therapists, counselors, and doctors to understand a patient's mental health status.
  • It can help track the effectiveness of treatment plans and make necessary adjustments.
  • It can facilitate more informed and productive conversations during therapy sessions.

Schools and Organizations:

  • Schools can use check-in forms to monitor the mental health of students and identify those who may need additional support.
  • Workplaces can use them to assess employee well-being and create a more supportive environment.
  • It allows for the tracking of general trends within a group.

Personal Support Networks:

  • Sharing check-in results with trusted friends or family members can facilitate open and honest conversations about mental health.
  • It can help support networks understand how to best support the individual.

3. Data Analysis and Trend Identification:

  • Quantifiable Data: The use of scales (e.g., 1-10) allows for the collection of quantifiable data that can be analyzed to identify trends and patterns.
  • Qualitative Data: Open-ended questions provide valuable qualitative data that can offer deeper insights into individual experiences.
  • Identifying Common Issues: Analyzing data from a group of individuals can reveal common mental health challenges and inform the development of targeted interventions.
  • Evaluating Interventions: Check-in forms can be used to evaluate the effectiveness of mental health programs and interventions.

4. Promoting Proactive Mental Health Management:

  • Encouraging Regular Check-ins: The form itself promotes the habit of regularly checking in with one's mental health.
  • Empowering Individuals: By providing a structured way to track their well-being, the form empowers individuals to take control of their mental health.
  • Reducing Stigma: Normalizing mental health check-ins can help reduce the stigma associated with mental health issues.

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