HOW ARE YOU FEELING
Questionnaire for seeking care
Yes or No answers,
(Please complete the brief form below to help us understand your needs. This
information is confidential and used only to connect you with appropriate care.) :
Yes or No answers
a. Emotional Well-being:
o Feeling persistently sad, anxious, overwhelmed, or emotionally numb
o Experiencing frequent mood swings or emotional outbursts
o Difficulty managing anger, stress, or frustration
b. Cognitive and Mental Functioning:
o Trouble focusing, concentrating, or remembering things
o Racing thoughts, excessive worry, or inability to relax
o Feeling mentally “stuck” or having negative thought patterns
c. Behavioral and Daily Functioning:
o Noticeable changes in sleep or appetite (too much or too little)
o Withdrawing from social activities or isolating from others
o Decline in work, school, or home responsibilities due to emotional strain
d. Physical Symptoms
o Frequent headaches, fatigue, or unexplained aches linked to stress
o Feeling constantly tense or on edge
o Panic attacks or rapid heartbeat without a medical cause
e. Coping and Resilience:
o Difficulty managing life transitions, grief, or trauma
o Reliance on alcohol, drugs, or other unhealthy coping mechanisms
o Feeling hopeless, helpless, or lacking motivation to move forward
f. Impact on Relationships:
o Strained family, romantic, or professional relationships
o Feeling misunderstood or unsupported by loved ones
o Fear of burdening others with your emotions
g. Readiness for Support: