Brief Norwalk Mental Health Survey

Please let us know how you are doing by completed this SHORT survey. We appreciate your time, and we will keep this survey ANONYMOUS.

Question Title

* 1. In what way has COVID19 affected your emotional well being?

Worse

No change/
The same

Better

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* 2. In what way has COVID19 affected your relationships with family and/or friends?

Worse

No change/
The same

Better

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* 3. Are you getting the mental health support you need right now?

Yes

No

Not sure

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* 4. Over the past 2 weeks how often have you been bothered by the following problems:

	Not at all	Several days	More than half of the days	Nearly every day
Little interest or pleasure in doing things	Little interest or pleasure in doing things Not at all	Little interest or pleasure in doing things Several days	Little interest or pleasure in doing things More than half of the days	Little interest or pleasure in doing things Nearly every day
Feeling down, depressed, or hopeless	Feeling down, depressed, or hopeless Not at all	Feeling down, depressed, or hopeless Several days	Feeling down, depressed, or hopeless More than half of the days	Feeling down, depressed, or hopeless Nearly every day
Feeling nervous, anxious or on edge	Feeling nervous, anxious or on edge Not at all	Feeling nervous, anxious or on edge Several days	Feeling nervous, anxious or on edge More than half of the days	Feeling nervous, anxious or on edge Nearly every day
Worrying too much about different things	Worrying too much about different things Not at all	Worrying too much about different things Several days	Worrying too much about different things More than half of the days	Worrying too much about different things Nearly every day

Click here to learn about all the counseling & peer services in Norwalk for youth & families.

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* 5. How concerned are you about your child's current level of:

	Not at all concerned	Slightly concerned	Very concerned	Extremely concerned
Stress and anxiety	Stress and anxiety Not at all concerned	Stress and anxiety Slightly concerned	Stress and anxiety Very concerned	Stress and anxiety Extremely concerned
Depression	Depression Not at all concerned	Depression Slightly concerned	Depression Very concerned	Depression Extremely concerned

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* 6. The Norwalk Partnership and Norwalk ACTS are hosting a Mental Health Walk and Wellness Fair on May 7th (raindate May 21st). Will you come?

Yes

No

Not sure/maybe

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* 7. Where do you live?

Norwalk

Other

Click here to get more information on NorWALK for Mental Health + Check-In Wellness Fair on May 7th! Hope you can join us!