Primary Counselor*Select your counselor hereRashad HameedHannah KidderMikare MichiraVictoria LindleyOtherYour Name* First Last Please rate the severity of your mental health symptoms today:Feelings of hopelessness/despair:*1=Minimal 5=Moderate 10=Severe 0 1 2 3 4 5 6 7 9 10 Feeling tired or having little energy:*1=Minimal 5=Moderate 10=Severe 0 1 2 3 4 5 6 7 9 10 Feeling bad about yourself, or hopeless about the future:*1=Minimal 5=Moderate 10=Severe 0 1 2 3 4 5 6 7 9 10 Thinking about harming yourself or that you'd be better off dead:*1=Minimal 5=Moderate 10=Severe 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 Please tell us about any thoughts of self-harm you may be experiencing: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 Please see a staff member immediately, so we can ensure you're getting the support you need! Thank you for completing this survey. You're done and can click "Submit" Δ
