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Template </h1> </header> <a href="https://wpforms.com/pricing/" class="button button-large" data-vars-ga-category="Templates Single" data-vars-ga-action="click" data-vars-ga-label="Use This Template (Bottom)">Use This Template</a> </div> </div> <div class="container single-container"> <div id="primary" class="site-content"> <main id="main" class="site-main" role="main"> <article class="post-23778 post type-post status-publish format-standard hentry category-health-wellness license-basic license-elite license-plus license-pro"> <div class="entry-content"> <div class="content-wpform-shortcode"> <div> <div class="wpforms-container wpforms-container-full form-template-disabled wpforms-container-save-resume wpforms-render-modern" id="wpforms-23777"><form id="wpforms-form-23777" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="23777" method="post" enctype="multipart/form-data" action="/templates/mental-health-self-assessment-form-template/" data-token="496e277f64ef2f46398e4e1c7e9ac0c5" data-token-time="1732571484"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-hidden" id="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</div><div class="wpforms-field-container"><div id="wpforms-23777-field_17-container" class="wpforms-field wpforms-field-divider" data-field-id="17"><h3 id="wpforms-23777-field_17" aria-errormessage="wpforms-23777-field_17-error">About You</h3></div><div id="wpforms-23777-field_1-container" class="wpforms-field wpforms-field-name" data-field-id="1"><fieldset><legend class="wpforms-field-label">Name <span class="wpforms-required-label" aria-hidden="true">*</span></legend><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-first wpforms-one-half"><input type="text" id="wpforms-23777-field_1" class="wpforms-field-name-first 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aria-errormessage="wpforms-23777-field_2-error" required></div><div id="wpforms-23777-field_4-container" class="wpforms-field wpforms-field-layout" data-field-id="4"><div class="wpforms-field-layout-rows wpforms-field-large"><div class="wpforms-layout-row"><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_5-container" class="wpforms-field wpforms-field-number" data-field-id="5"><label class="wpforms-field-label" for="wpforms-23777-field_5">Age <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="number" id="wpforms-23777-field_5" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][5]" aria-errormessage="wpforms-23777-field_5-error" required></div></div><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_6-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="6"><label class="wpforms-field-label" for="wpforms-23777-field_6">Gender <span class="wpforms-required-label" aria-hidden="true">*</span></label><select id="wpforms-23777-field_6" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][6]" required="required"><option value="Male" >Male</option><option value="Female" >Female</option><option value="Prefer not to say" >Prefer not to say</option></select></div></div></div></div></div><div id="wpforms-23777-field_18-container" class="wpforms-field wpforms-field-divider" data-field-id="18"><h3 id="wpforms-23777-field_18" aria-errormessage="wpforms-23777-field_18-error">Self-Assessment</h3></div><div id="wpforms-23777-field_15-container" class="wpforms-field wpforms-field-layout" data-field-id="15"><div class="wpforms-field-layout-rows wpforms-field-large"><div class="wpforms-layout-row"><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_7-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="7"><label class="wpforms-field-label" for="wpforms-23777-field_7">Current Mood <span class="wpforms-required-label" aria-hidden="true">*</span></label><select id="wpforms-23777-field_7" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][7]" required="required"><option value="Happy" >Happy</option><option value="Sad" >Sad</option><option value="Anxious" >Anxious</option><option value="Calm" >Calm</option><option value="Angry" >Angry</option><option value="Confused" >Confused</option><option value="Overwhelmed" >Overwhelmed</option><option value="Content" >Content</option><option value="Frustrated" >Frustrated</option><option value="Excited" >Excited</option><option value="Bored" >Bored</option><option value="Motivated" >Motivated</option><option value="Tired" >Tired</option><option value="Stressed" >Stressed</option><option value="Hopeful" >Hopeful</option></select></div></div><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_9-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="9"><label class="wpforms-field-label" for="wpforms-23777-field_9">Sleep Quality <span class="wpforms-required-label" aria-hidden="true">*</span></label><select id="wpforms-23777-field_9" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][9]" required="required"><option value="Good" >Good</option><option value="Fair" >Fair</option><option value="Poor" >Poor</option></select></div></div></div><div class="wpforms-layout-row"><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_10-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="10"><label class="wpforms-field-label" for="wpforms-23777-field_10">Appetite Changes <span class="wpforms-required-label" aria-hidden="true">*</span></label><select id="wpforms-23777-field_10" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][10]" required="required"><option value="Increased" >Increased</option><option value="Decreased" >Decreased</option><option value="No Change" >No Change</option></select></div></div><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_8-container" class="wpforms-field wpforms-field-number-slider" data-field-id="8"><label class="wpforms-field-label" for="wpforms-23777-field_8">Stress Level</label> <input type="range" id="wpforms-23777-field_8" class="wpforms-field-medium" name="wpforms[fields][8]" value="0" aria-errormessage="wpforms-23777-field_8-error" min="0" max="10" step="1"> <div class="wpforms-field-number-slider-hint" data-hint="Selected Value: {value}"> Selected Value: <b>0</b></div> </div></div></div></div></div><div id="wpforms-23777-field_3-container" class="wpforms-field wpforms-field-textarea" data-field-id="3"><label class="wpforms-field-label" for="wpforms-23777-field_3">Recent Life Changes or Stressors <span class="wpforms-required-label" aria-hidden="true">*</span></label><textarea id="wpforms-23777-field_3" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][3]" aria-errormessage="wpforms-23777-field_3-error" required></textarea></div><div id="wpforms-23777-field_11-container" class="wpforms-field wpforms-field-textarea" data-field-id="11"><label class="wpforms-field-label" for="wpforms-23777-field_11">Physical Health Concerns (if any)</label><textarea id="wpforms-23777-field_11" class="wpforms-field-medium" name="wpforms[fields][11]" aria-errormessage="wpforms-23777-field_11-error" ></textarea></div> <div id="wpforms-23777-field_13-container" class="wpforms-field wpforms-field-text" data-field-type="text" data-field-id="13" > <label class="wpforms-field-label" for="wpforms-23777-field_13" >Sleep Life Changes</label> <input type="text" id="wpforms-23777-field_13" class="wpforms-field-medium" name="wpforms[fields][13]" > </div> <div id="wpforms-23777-field_16-container" class="wpforms-field wpforms-field-layout" data-field-id="16"><div class="wpforms-field-layout-rows wpforms-field-large"><div class="wpforms-layout-row"><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_12-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="12"><label class="wpforms-field-label" for="wpforms-23777-field_12">Support System <span class="wpforms-required-label" aria-hidden="true">*</span></label><select id="wpforms-23777-field_12" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][12]" required="required"><option value="Family" >Family</option><option value="Friends" >Friends</option><option value="Therapist" >Therapist</option><option value="Counselor" >Counselor</option><option value="Other" >Other</option></select></div></div><div class="wpforms-layout-column wpforms-layout-column-50"><div id="wpforms-23777-field_14-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="14"><label class="wpforms-field-label" for="wpforms-23777-field_14">Interested in Professional Help <span class="wpforms-required-label" aria-hidden="true">*</span></label><select id="wpforms-23777-field_14" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][14]" required="required"><option value="No" >No</option><option value="Yes" >Yes</option></select></div></div></div></div></div><script> ( function() { const style = document.createElement( 'style' ); style.appendChild( document.createTextNode( '#wpforms-23777-field_13-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-23777-field_13-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-23777-field_13-container label { counter-increment: none; }' ) ); document.head.appendChild( style ); document.currentScript?.remove(); } )(); </script></div><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="23777"><input type="hidden" name="page_title" value="Mental Health Self-Assessment Form Template"><input type="hidden" name="page_url" value="https://wpforms.com/templates/mental-health-self-assessment-form-template/"><input type="hidden" name="page_id" value="23778"><input type="hidden" name="wpforms[post_id]" value="23778"><button type="submit" name="wpforms[submit]" id="wpforms-submit-23777" class="wpforms-submit" data-alt-text="Sending..." data-submit-text="Submit" aria-live="assertive" value="wpforms-submit">Submit</button><img src="https://wpforms.com/templates/wp-content/plugins/wpforms/assets/images/submit-spin.svg" class="wpforms-submit-spinner" style="display: none;" width="26" height="26" alt="Loading"></div></form></div>  <div class="block-required-plan block"> <div class="block-container"> <a href="https://wpforms.com/pricing/" class="plan-notice-box"> <div class="plan-badge-holder"> <span class="plan-badge">basic</span> </div> <span>This template includes features available in WPForms Basic. <span class="plan-compare">Compare Plans</span></span> </a> </div> </div> </div> </div> <div class="single-template-content"> <p>The Mental Health Self-Assessment Form template offers an easy way for individuals to evaluate their mental and emotional state. Whether used by healthcare providers or wellness organizations, this form helps users identify potential issues and encourages them to seek help if needed.</p> <h3>Using the Mental Health Self-Assessment Form Template</h3> <p>Here’s a breakdown of the form and its importance:</p> <ul> <li><strong>About You</strong>: Name, email, and age fields help to personalize the assessment and ensure follow-up communication, if applicable. The gender dropdown adds context to the individual’s experience, as mental health can be impacted by gender-related factors.</li> <li><strong style="letter-spacing: 0.25px;">Current Mood</strong><span style="letter-spacing: 0.25px;">: This dropdown provides 15 mood options, including states like “happy,” “anxious,” or “stressed.” By selecting how they feel in the moment, individuals can better recognize patterns in their emotional well-being.</span></li> <li><strong style="letter-spacing: 0.25px;">Sleep Quality</strong><span style="letter-spacing: 0.25px;">: Sleep is often a strong indicator of mental health, and users can choose whether they feel their sleep has been “Good,” “Fair,” or “Poor.”</span></li> <li><strong style="letter-spacing: 0.25px;">Appetite Changes</strong><span style="letter-spacing: 0.25px;">: Fluctuations in appetite are common signs of emotional stress or depression. The dropdown allows users to identify if their appetite has increased, decreased, or remained unchanged.</span></li> <li><strong style="letter-spacing: 0.25px;">Stress Level</strong><span style="letter-spacing: 0.25px;">: The Stress Level slider (0-10) gives users the opportunity to quantify their current stress, offering a more precise insight into how overwhelmed they might feel.</span></li> <li><strong style="letter-spacing: 0.25px;">Recent Life Changes or Stressors</strong><span style="letter-spacing: 0.25px;">: Users can describe major life events or stressors that may be impacting their mental health, such as job loss, family issues, or financial challenges.</span></li> <li><strong style="letter-spacing: 0.25px;">Physical Health Concerns</strong><span style="letter-spacing: 0.25px;">: Since physical and mental health are often interconnected, this open-ended field allows users to list any physical symptoms or medical issues that could be affecting their mental state.</span></li> <li><strong style="letter-spacing: 0.25px;">Support System</strong><span style="letter-spacing: 0.25px;">: Recognizing one’s support network is crucial for mental well-being. Users can select from options like family, friends, therapist, or counselor, helping them reflect on who they can rely on during challenging times.</span></li> <li><strong style="letter-spacing: 0.25px;">Interest in Professional Help</strong><span style="letter-spacing: 0.25px;">: This option allows users to express whether they are interested in seeking professional support. It’s a critical step in recognizing when assistance from a mental health professional may be necessary.</span></li> </ul> <p>For wellness websites, counseling services, or healthcare providers, integrating this form provides a non-intrusive way for visitors to assess their mental health, encouraging early intervention and promoting overall well-being. Get the Mental Health Self-Assessment Form template from WPForms today.</p> </div> </div> </article> </main> </div> </div> <div class="container wpf-pro-cta"> <a href="https://wpforms.com/pricing/" class="button button-large" data-vars-ga-category="Templates Single" data-vars-ga-action="click" data-vars-ga-label="Get WPForms Pro (Bottom)">Get WPForms Pro</a> </div> <div class="related-templates-wrap"> <h2 class="title">Looking for something else?</h2> <p>Here are some other <a href="https://wpforms.com/templates/category/health-wellness">Health & Wellness form templates</a></p> <div class="related-templates-grid templates-list"> <div class="template-demo-block "> <div class="thumb-template"> <a href="https://wpforms.com/templates/counseling-session-request-form-template/"><img src="https://wpforms.com/templates/wp-content/uploads/templates/thumb/6b5bca6ae4acd2fadbc8e564b9c610ec.jpg" alt="Counseling Session Request Form Template"></a> </div> <div class="content"> <header 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</div> <div class="content"> <header class="entry-header"> <h3 title="Child Care Provider Inquiry Form Template" class="entry-title"> <a href="https://wpforms.com/templates/child-care-provider-inquiry-form-template/">Child Care Provider Inquiry Form </a> </h3> </header> <p class="entry-description">Gather important information from parents to help care providers plan. </p> </div> <div class="actions"> <a href="https://wpforms.com/pricing/" class="button" data-vars-ga-category="Templates" data-vars-ga-action="click" data-vars-ga-label="Use Template">Use Template</a> <a href="https://wpforms.com/templates/child-care-provider-inquiry-form-template/" class="button button-light-gray">View Demo</a> </div> </div> <div class="template-demo-block "> <div class="thumb-template"> <a href="https://wpforms.com/templates/yoga-class-signup-form-template/"><img src="https://wpforms.com/templates/wp-content/uploads/templates/thumb/55396fa9e282635aff8d106de8d37e70.jpg" alt="Yoga Class Signup Form 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