Contact – LivesConnect

Endorse the following symptoms which impact your life:*

Agitation

Anxiety

Auditory hallucinations, ‘voices’

Crying, teary-eyed

Depressed mood

Difficulty concentrating

Excessive eating (to cope with emotions)

Excessive sleep

Fear

Feelings of Hopelessness

Lack of appetite

Loneliness

Low energy

Mania, or Euphoria

Panic

Paranoia

Poor appetite

Visual hallucinations

Do you experience a depressed mood on most days?*

Yes

No

Have you experienced depression for at least six months?*

Yes

No

I am often crying due to minor or unclear events.*

Yes

No

Are you struggling with stress adjusting to a major life event or change?*

Yes

No

Do you struggle with low energy or feeling lethargic on most days?*

Yes

No

Do you lack motivation on most days?*

Yes

No

Does a lack of motivation/energy interfere with your productivity at home?*

Yes

Some

No

Does a lack of motivation/energy interfere with your productivity at work?*

Yes

Some

No

Do you struggle with sustaining focus on most days?*

Yes

No

Does your difficulty sustaining focus interfere with your productivity at home?*

Yes

Some

No

Does your difficulty sustaining focus interfere with your productivity at work?*

Yes

Some

No

Do you struggle with ongoing worrying on most days?*

Yes

No

Do your emotional struggles notably interfere with your relationships in your life?*

Yes

No

I’m typically agitated when spending time with others?*

Yes

No

I typically cope with conflicting emotions by using alcohol or drugs?*

Yes

No

Have you been diagnosed with a mental illness in the last five years?*

Yes

No

If so, what were you diagnosed with (if known)?*

If you’ve been prescribed psychiatric medication in the last year, what are those medications?*

Are you currently taking psychiatric medications?*

Yes

No

Have you ever been hospitalized in a psychiatric unit due to mental health issues?*

Yes

No

Have you been in therapy with a counselor, psychologist or mental health provider in the last year?*

Yes

No

Does your animal provide you with a strong sense of purpose (e.g., care, feeding)?*

Yes

No

Does your animal provide you with outlets of physical activity (e.g., walking, dog park, fetch)?*

Yes

No

Do you struggle with anxiety due to not feeling safe when your animal is not present?*

Yes

No

Your Name*

Zip Code*

Phone Number*

Email*

Type of Pet

Breed

Pet’s Name

Pet’s Weight

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Comprehensive Mental and Physical Health Self-Assessment