Free Assessment Please enter your name, or the name of the person who will receive care from Bloomwell. This will be kept confidential. Zip Code 2. What is the client's age? Less than 13 years old Between 13 & 17 years old Between 18 & 64 years old 65 years and older 3. Who is signing up tonight? I’m an adult signing up for myself I’m a parent or guardian signing up for my teen I’m a teen signing up for myself 4. What can we help you with today? (Select all that apply) Depression Anxiety Insomnia Panic Bipolar disorder Obsessive compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Social anxiety Phobia Postpartum depression Burnout Binge eating / eating disorders ADD / ADHD Substance or Alcohol Use Issues Persistent depressive disorder Seasonal affective disorder (SAD) Premenstrual dysphoric disorder (PMDD) Relationship issues Workplace Stress Something else I'm not sure What brings you to seek support at this time? 6. On a scale from 1 to 10, how would you rate the impact of your current struggles on your daily life? 1-2 – My struggles have little to no impact on my daily life; I’m generally able to function as usual. 3-4 – My struggles occasionally affect my daily life, but I can usually manage them without significant disruption. 5-6 – My struggles moderately impact my daily life; I sometimes find it difficult to complete tasks or engage with others. 7-8 – My struggles frequently affect my daily life; I often find it hard to stay focused, maintain relationships, or meet responsibilities. 9-10 – My struggles severely impact my daily life; they consistently interfere with my ability to function in multiple areas (work, school, family, social life). 7. Have you experienced any of the following symptoms consistently for more than two weeks? (Select all that apply) Persistent feelings of sadness or hopelessness Difficulty sleeping or sleeping too much Intense worry or feelings of fear Difficulty concentrating or completing tasks Changes in eating habits or weight (Check all that apply to get a sense of the client’s symptom patterns.) 8. How often do you find it challenging to manage daily stress or cope with emotions? Rarely Sometimes Often Almost always Have you been diagnosed with any mental health conditions in the past, or have you received any treatment such as therapy or medication? Send
