Request appointment | WorkLife Wellness Lab

What is the reason for seeking care?

Anxiety Attentional or executive function difficulties Behavioral concerns Depression Grief Relationship issues Substance use Trauma Vocational Rehabilitation Assessment or Evaluation Vocational Rehabilitation Personal Adjustment, Work Adjustment, or Job Coaching Other

Over the past two weeks, how would you describe your overall mood?

Doing well — no significant concerns impacting my daily life, work, or relationships My mood feels challenging at times but is generally manageable day to day, with limited impact on my daily life, work, or relationships My mood has been disruptive to my daily life, work, or relationships and affects me in a noticeable way My mood has been overwhelming or disabling and has significantly impacted my daily life, work, or relationships, and I find myself disengaging more often than not

Over the past 2 weeks, how often have anxiety, worry, or feeling on edge interfered with your daily life or work?

Not at all A few days (1–4 days) Most days (5–10 days) Almost every day (11–14 days)

Over the past two weeks, have you experienced distress related to past or recent trauma's i.e., medical events, accidents, major life events, or ongoing work or life stress? Select the response that best fits.

Not at all Yes, and it is noticeable but manageable Yes, and it is frequently disruptive but I can still go about my day Yes, and it is overwhelming or disabling and keeps me from normal daily activities

Over the past two weeks, how much have emotional or mental health concerns affected your ability to function at work, home, or daily tasks?

Not at all — no impact on my daily functioning There is some impact, but it is generally manageable and I can still carry out most daily responsibilities The impact has been noticeable and frequently disruptive to my daily life and responsibilities The impact has been overwhelming or disabling and has prevented me from functioning normally

Over the past two weeks, how often have you struggled with focus, organization, follow-through, or feeling mentally overwhelmed?

Not at all (0 days) A few days (1–4 days) Most days (5–10 days) Almost every day (11–14 days)

Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?

Not at all (0 days) A few days (1–4 days) Most days (5–10 days) Almost every day (11–14 days)

Please list any medications, supplements, or substances you are currently using prescribed, over-the-counter, or self-directed. This information will help us to provide you with safe, accurate, and coordinated care.

For each item, include: the name of medication or substance, how often you take it, whether it is prescribed by a provider or self-directed, and the reason you use it..

Limited to 600 characters

Please list any mental health conditions or chronic health conditions you have. Indicate whether you have been formally been diagnosed by a provider or you have self-identified.

Limited to 600 characters

To support holistic, coordinated care, please list any other therapists, counselors, psychiatrists, medical providers, coaches, or support services you are currently working with.

For each, include if possible: • provider type or role • focus of care

Limited to 600 characters

Have you noticed any of the following recently that feel unusual or concerning for you?

Check all that apply

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