Daily Depression & Self-Harm Survey 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=Severe01234567910Feeling tired or having little energy:*1=Minimal 5=Moderate 10=Severe01234567910Feeling bad about yourself, or hopeless about the future:*1=Minimal 5=Moderate 10=Severe01234567910Thinking about harming yourself or that you'd be better off dead:*1=Minimal 5=Moderate 10=Severe01234567910Would you like to meet with a staff member to talk about your symptoms today?*NoYesPlease tell us about any thoughts of self-harm you may be experiencing:Are you having thoughts of hurting yourself today?*NoYesPlease tell us more about those thoughts:Just a couple thoughts with no plan or intentSeveral thoughts with some urges to harm myselfMany troubling thoughts and a developing planVery troubling thoughts and a specific plan to harm myselfExtremely 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"
