About this template
A Mental Wellbeing Assessment Form provides a structured, compassionate way for mental health professionals, counselors, and wellness program coordinators to evaluate an individual's emotional state and mental health. This template gathers essential insights into recent anxiety and depression symptoms, daily functioning levels, and personal coping mechanisms.
Using Doc2Form to deploy this assessment as a Google Form allows practitioners to streamline client intake and wellness check-ins without complicated software setups. Clients can complete the questionnaire privately from any device before a session, giving practitioners valuable context ahead of time. This digital format ensures that sensitive data is collected consistently and stored securely within your existing workspace ecosystem.
Whether you run a private practice, a wellness clinic, or a corporate support program, this template helps you establish a reliable baseline for client care. By standardizing how you assess mental wellbeing, you can identify potential concerns early, track progress over time, and tailor your support and treatment plans more effectively to each individual.
Key features
- Evaluate symptom frequency and daily functioning in minutes
- Standardize mental health intakes across sessions or programs
- Securely collect client insights directly into Google Drive
- Mobile-friendly format for easy completion on any device
Use cases
- Initial intake assessments for new therapy clients
- Periodic mental health check-ins for employee wellness programs
- Progress tracking for ongoing counseling and coaching sessions
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Email Address (Short answer)Where can we reach you if needed?
- Anxiety Symptom Frequency (Past 2 Weeks) (Multiple choice)Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
- Depression Symptom Frequency (Past 2 Weeks) (Multiple choice)Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
- Daily Functioning Difficulty Level (Dropdown)If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
- Overall Stress Level (Linear scale)Rate your current overall level of stress on a scale from 1 to 5.
- Sleep Quality (Multiple choice)How would you rate your average sleep quality over the past week?
- Additional Information (Paragraph)Please share anything else you would like your counselor or support team to know about your current wellbeing.
FAQ
How can I customize this mental wellbeing assessment?
Once generated in Google Forms, you can easily add, remove, or edit questions, adjust rating scales, and apply your practice branding using standard Google Forms editing tools.
Is this form template secure for sensitive health data?
Google Forms operates within your secure Google Workspace account, allowing you to manage sharing permissions and access controls according to your organization's internal privacy standards.
Can clients complete this form on their mobile phones?
Yes, Google Forms automatically adapts to mobile devices, tablets, and desktop computers for a smooth respondent experience.
How do I share this assessment with clients?
You can share the form via a direct link, embed it on your private website, or send it directly via email as part of your onboarding workflow.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.