After submitting form, we will call you for confirmation. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Whats your name *Before we get started, how are you feeling today?Happy 😄Worried 🥲Stressed 😰Relaxed 🤓Sad 😞Angry 😡Not sure 😑Think about the past couple weeks. Have you felt any of these?Stressed or burned outProblems with sleep – trouble falling or staying asleep, or sleeping too muchNervous, anxious, or on edgeLonelyLittle interest or pleasure in doing thingsDown, depressed or hopelessMore irritable than usualTrouble focusing and motivatingIn the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?This question is required.*Not at allSeveral daysMore than half the daysNearly everyday in the last 2 weeks, how often have you been bothered by trouble falling or staying asleep, or sleeping too much?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by feeling tired or having little energy?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by poor appetite or overeating?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by feeling bad about yourself — or that you are a failure or have let yourself or your family down?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?Not at allSeveral daysMore than half the daysNearly everydayIn the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or hurting yourself in some way?Not at allSeveral daysMore than half the daysNearly everydayHow difficult have these feelings made it for you to do your work, take care of things at home, or get along with others? *Not at allSeveral daysMore than half the daysNearly everydayHow old are you? *What was your sex assigned at birth? *MaleFemaleWhat is your gender? *ManWomenTransgender ManTransgender WomanGenderqueer / Non binaryAgenderOtherPhone *Email *Submit
