1. What is your gender?

2. Can you share your relationship status?

3. Are you presently employed?

4. How would you rate your physical well-being right now?

5. During the past two weeks, how would you rate your sleep quality?

6. During the past two weeks, how would you rate your eating behavior?

7. Have you been feeling exhausted or uninterested in doing things?

8. Have you been overwhelmed by sadness, grief, or depression?

9. Have you been feeling alone, or disconnected from others?

10. Have you been fidgety, anxious, or nervous lately?

11. Have you been having a hard time focusing or concentrating?

12. Have you thought of hurting yourself?

13. Have you thought of taking your own life?

14. How frequently do you consume alcohol?

15. Is there a current worry or a persistent stressful situation that is interfering with your happiness?

16. Have you previously sought counseling or therapy?

17. How did you hear about us?

18. Would you prefer to talk with a male or female therapist?