Student Mental Health Check-in Survey Template

1. What is your age?

The answer should be a single choice:

1. Under 18
2. 18-24
3. 25-34
4. 35-44
5. 45 or older

2. What is your gender?

The answer should be a single choice:

1. Male
2. Female
3. Other
4. Prefer not to say

3. What is your current level of education?

The answer should be a single choice:

1. High school
2. Undergraduate
3. Graduate

4. How often have you felt overwhelmed in the past month?

The answer should be a single choice:

1. Never
2. Rarely
3. Sometimes
4. Often
5. Always

5. Have you experienced any of the following in the past month? (Select all that apply)

The answer should be a single choice:

1. Persistent sadness or hopelessness
2. Anxiety or excessive worry
3. Panic attacks
4. Suicidal thoughts
5. None of the above

6. On a scale of 1-10, how would you rate your overall mental health in the past month?

The answer should be a single choice:

1. 1 (very poor)
2. 2
3. 3
4. 4
5. 5 (average)
6. 6
7. 7
8. 8
9. 9
10. 10 (excellent)

7. Which of the following have you used to cope with stress or negative feelings in the past month? (Select all that apply)

The answer should be a multiple choice:

1. Exercise
2. Talking to a friend or family member
3. Meditation or mindfulness practices
4. Watching TV or movies
5. Substance use (alcohol, drugs)
6. None of the above

8. How effective have your coping strategies been in managing stress or negative feelings?

The answer should be a single choice:

1. Not effective at all
2. Somewhat effective
3. Moderately effective
4. Very effective
5. Extremely effective

9. Have you sought help for mental health issues in the past?

The answer should be a single choice:

1. Yes
2. No

10. If you answered yes to question 9, what resources did you use? (Select all that apply)

The answer should be a multiple choice:

1. Therapy or counselling services
2. Medication prescribed by a doctor
3. Support groups
4. Online resources or self-help materials
5. None of the above
6. N/A

11. If you answered no to question 9, what barriers have prevented you from seeking help? (Select all that apply)

The answer should be a multiple choice:

1. Stigma or shame
2. Lack of access to resources
3. Financial barriers
4. Lack of time
5. Belief that the issue will resolve on its own
6. N/A