Partner Track: Mental Health Assessment

Name *

First

Last

Email *

Please check any symptoms you are currently experiencing or have experienced in the past 30 days. Please also check any formal diagnoses given you by a doctor. *

depression/depressive episodes
hopelessness
mood swings
anxiety
panic attacks
loss of interest or pleasure in activities
euphoria
excess sleepiness or insomnia
suicide ideation (thoughts of suicide, making a plan, fantasizing about dying)
suicide attempt
self-harming
impulsivity (lack of control over your behavior)
risky behavior
memory loss
aggression
a belief that your thoughts aren't your own
excitability
social isolation
confusion
paranoia
visual, auditory, and/or olfactory hallucinations
rapid or frenzied speech
repetitive movements
belief that you are being watched or persecuted
fear of abandonment
explosive anger or rage that can be violent
compulsive behavior
lack of concentration
general discontent with your life/circumstances
addiction/alcoholism
self-medicating with alcohol, drugs, painkillers, porn, gaming, gambling, marijuana, etc.
disordered eating (doesn't matter if it has been formally diagnosed or not)
diagnosed Major Depressive Disorder MDD
diagnosed Generalized Anxiety Disorder GAD or Panic Disorder
diagnosed Bipolar Disorder (1 or 2)
diagnosed Schizophrenia
diagnosed Borderline Personality Disorder BPD
diagnosed PTSD
diagnosed Postpartum Depression PPD or Postpartum Anxiety PPA
diagnosed Obsessive-Compulsive Disorder OCD
diagnosed Dissociative Disorder
diagnosed Psychotic Disorder or Psychosis
other

If you checked "Other" above, please use as much space as you need to elaborate.

If you are currently taking any prescribed psychiatric medications, please list them here along with your dosing and schedule:

If you are currently using any non-pharmaceutical substance (cannabis, CBD, anti-histamines, herbal tinctures, supplements, homeopathy, etc.) to alleviate mental health symptoms, please list them here along with your dosing and schedule:

Family Mental Health History: to the best of your ability, please mark any symptoms or diagnoses experienced by members of your immediate family (parents, siblings) *

If you checked "Other" above, please use as much space as you need to elaborate.

Please herbal additional

Use as much space as you need to let Lindsey know any additional information about your mental health that you feel is relevant: