Survey

Please answer the following questions**.

All fields are required.

1. In general, would you say your health is? * (required) This question is required

2. In general, would you say your mental health is? * (required)

3. In general, would you say your ability to get along with others (family, friends, coworkers) is? * (required)

Over the last 2 weeks, how often have you been bothered by the following problems

4. Little interest or pleasure in doing things * (required)

5. Feeling down, depressed, or hopeless * (required)

6. Trouble falling or staying asleep, or sleeping too much * (required)

7. Feeling tired or having little energy * (required)

8. Poor appetite or overeating * (required)

9. Feeling bad about yourself - or that you are a failure or have let yourself or your family down * (required)

10. Trouble concentrating on things, such as reading the newspaper or watching television * (required)

11. 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 * (required)

12. Thoughts that you would be better off dead, or of hurting yourself in some way * (required)

13. 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 * (required)

Your answers to the assessment are confidential. If you choose to participate in the Take Charge at Work telephonic coaching program, your results will be shared with your coach at that time.