Daily Depression & Self-Harm Survey
Primary Counselor
*
Please Select
Rashad Hameed
Hannah Kidder
Mikare Michira
Victoria Lindley
Other
Name
*
First Name
Last Name
Feelings of hopelessness or despair:
*
0
1
2
3
4
5
6
7
9
10
Feeling tired or having little energy:
*
0
1
2
3
4
5
6
7
9
10
Feeling bad about yourself, or hopeless about the future:
*
0
1
2
3
4
5
6
7
9
10
Thinking about harming yourself or that you'd be better off dead:
*
0
1
2
3
4
5
6
7
9
10
Would you like to meet with a staff member to talk about your symptoms today?
*
No
Yes
Are you having thoughts of hurting yourself today?
*
No
Yes
Please tell us more about those thoughts:
Just a couple thoughts with no plan or intent
Several thoughts with some urges to harm myself
Many troubling thoughts and a developing plan
Very troubling thoughts and a specific plan to harm myself
Extremely troubling thoughts with an active plan and intent to harm myself
Submit
Should be Empty: