Your Mental Wellness Check-In
Important Notice: Disclaimer and Consent
This self-screening check-in is intended as a self-awareness and reflection tool to help individuals identify concerns that may benefit from further mental health support. This check-in considers six areas commonly associated with emotional wellbeing and mental health concerns, namely: "Depression & Emotional Wellbeing, Anxiety & Stress, Trauma & PTSD, Mood & Emotional Regulation, Functioning, Sleep & Relationships and Important Safety Screening". It is not a diagnostic tool and does not constitute medical advice, treatment, or a professional assessment. Completion of this check-in does not establish a healthcare practitioner-patient relationship. The information you provide will be treated confidentially and processed in accordance with applicable privacy and data protection legislation. By submitting this check-in, you consent to being contacted by a member of our team regarding your enquiry and available treatment options.
Please note that submissions made through this platform are not monitored continuously and should not be relied upon for urgent, emergency, or crisis intervention. While we endeavour to review enquiries as soon as reasonably practicable, we cannot guarantee an immediate response. Although we strive to provide timely assistance, the Clinic, its employees, practitioners, and representatives cannot accept responsibility for any loss, damage, injury, harm, or adverse outcome arising from reliance on this check-in or from delays in receiving, reviewing, or responding to information submitted through this platform.
Please contact emergency services, your nearest emergency department, your treating healthcare professional, or an appropriate crisis support service immediately.
Depression & Emotional Wellbeing
How often have you experienced the following during the past 3–6 months?
1. I have felt sad, down, hopeless, or tearful.
2. I have lost interest in activities I usually enjoy.
3. I have felt tired, drained, or lacking in energy.
4. I have struggled to concentrate or make decisions.
5. I have felt worthless, guilty, or like a burden.
6. I have noticed significant changes in my appetite or weight.
Anxiety & Stress
How often have you experienced the following during the past 3–6 months?
7. I have felt nervous, anxious, or on edge.
8. I have struggled to control excessive worrying.
9. I have experienced physical symptoms of anxiety (e.g., racing heart, sweating, tension).
10. I have avoided certain situations due to fear or anxiety.
11. My worries have interfered with my daily functioning.
12. I have felt overwhelmed by stress or responsibilities.
Trauma & PTSD
How often have you experienced the following during the past 3–6 months?
13. Disturbing memories of a stressful or traumatic event have bothered me.
14. I have experienced upsetting dreams or nightmares.
15. I avoid reminders of a difficult or traumatic experience.
16. I feel constantly alert, watchful, or easily startled.
17. I feel emotionally numb or detached from others.
Mood & Emotional Regulation
How often have you experienced the following during the past 3–6 months?
18. My mood changes rapidly without a clear reason.
19. I become irritable, frustrated, or angry more easily than usual.
20. I experience periods of unusually high energy or restlessness.
21. My emotions feel difficult to control.
22. I have acted impulsively and later regretted my actions.
Functioning, Sleep & Relationships
How often have you experienced the following during the past 3–6 months?
23. My emotional or mental wellbeing has made it difficult for me to cope with everyday responsibilities, tasks, or challenges that I would normally be able to manage.
24. I have withdrawn from family, friends, or social activities.
25. I have experienced ongoing difficulties with sleep (too little, too much, or poor-quality sleep).
26. Do you feel you have adequate emotional support from family or friends?
27. Have you increased your use of alcohol, medication, or other substances to cope with stress?
28. My emotional or mental wellbeing has negatively affected my work, studies, daily responsibilities, or ability to maintain my usual level of self-care and personal hygiene.
29. I experience physical symptoms (such as headaches, fatigue, muscle tension, stomach problems, pain, dizziness, or other unexplained physical complaints) for which no clear medical cause has been identified.
Important Safety Screening
Please answer honestly. Your responses are confidential and help ensure you receive the most appropriate support.
30. Have you intentionally harmed yourself or thought about harming yourself?
31. Have you felt that life is not worth living?
32. Have you had thoughts of ending your life?
33. Have you experienced panic attacks?
34. Have you experienced unusual perceptions such as hearing voices or seeing things others do not?
35. I have experienced intense anger, aggressive thoughts, or thoughts of harming another person / people.
Additional Screening Questions
Please select all options that apply.
36. Which of the following stressors are currently affecting you? (select all that apply)
37. Have you previously received treatment from a psychologist, psychiatrist, rehabilitation programme, or mental health facility?
38. What type of support are you seeking? (select all that apply)
Your Contact Details
To allow our team to follow up with you, please complete the form below. All information is treated as strictly confidential.