EAP Wellbeing Assessment Questionnaire - Triangle Mental Health Foundation

Employees Questionnaire

For employees covered by the Triangle Foundation Employee Assistant Programme (EAP

To make an appointment please complete section 1 – 5

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Section 1

Our stress and well-being questionnaire is designed as an initial assessment tool to help us understand your emotional state, it is not a diagnostic tool.

Please answer as many questions as possible to provide us with an initial insight into your current emotional state.

Please tick this box. You are required to ✔ the box to show that you have read and accept our policy before completing the questionnaire.

Before completing this form, please inform us of any professional mental health related support that you are currently receiving or are taking prescribed medication.

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Referred by or self-referred*

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Questions with* are mandatory

Employers / Organisations Name*

Branch employed* (where applicable)

Position*

Employees Details

Full Name*

Date of Birth* ×

Address line one*

Address line two*

Country*

County*

Postal Code*

Phone Number*

Email*

Symptoms of (SAD) Stress - Anxiety - DepressionAnxiety

Anxiety - Section 2*

Over the last two weeks, how often have experienced any of the following anxiety statements

	Not at all	Several Days	More than half the days	Nearly every day
	Not at all	Several Days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Symptoms of (SAD) Stress - Anxiety - DepressionDepression

Over the last two weeks, how often have experienced any of the following depression statements

Depression - Section 3*

Over the last two weeks, how often have experienced any of the following anxiety statements

	Not at all	Several Days	More than half the days	Nearly every day
	Not at all	Several Days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Thoughts that you would be better off dead, or of hurting yourself
Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual

Employees Questionnaire

Section 1

Questions with* are mandatory

Employees Details

Life events inventory

Symptoms of (SAD) Stress - Anxiety - DepressionPhysical Signs

Symptoms of (SAD) Stress - Anxiety - Depression Cognitive signs

Symptoms of (SAD) Stress - Anxiety - DepressionEmotional signs

Symptoms of (SAD) Stress - Anxiety - DepressionBehavioural signs

Symptoms of (SAD) Stress - Anxiety - DepressionAnxiety

Symptoms of (SAD) Stress - Anxiety - DepressionDepression

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