Newtopia’s Mental Health Program Screener – Levi Strauss - Oct. 2022

Welcome!

Please complete the brief survey below so we can determine the best way to support you/your mental health and wellbeing. Your privacy is our biggest concern. We do not share your information with your employer or your insurer. Your privacy is 100% guaranteed.

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* Over the last 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

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* Over the last 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
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
Not being able to stop or control worrying	Not being able to stop or control worrying Not at all	Not being able to stop or control worrying Several days	Not being able to stop or control worrying More than half of the days	Not being able to stop or control worrying Nearly every day

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* In the last month, how often have you felt or thought the following:

	Never	Almost never	Sometimes	Fairly often	Very often
Felt that you were unable to control the important things in your life?	Felt that you were unable to control the important things in your life? Never	Felt that you were unable to control the important things in your life? Almost never	Felt that you were unable to control the important things in your life? Sometimes	Felt that you were unable to control the important things in your life? Fairly often	Felt that you were unable to control the important things in your life? Very often
Felt difficulties were piling up so high that you could not overcome them?	Felt difficulties were piling up so high that you could not overcome them? Never	Felt difficulties were piling up so high that you could not overcome them? Almost never	Felt difficulties were piling up so high that you could not overcome them? Sometimes	Felt difficulties were piling up so high that you could not overcome them? Fairly often	Felt difficulties were piling up so high that you could not overcome them? Very often

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* In the last month, how often have you felt or thought the following:

	Never	Almost never	Sometimes	Fairly often	Very often
Felt confident about your ability to handle your personal problems?	Felt confident about your ability to handle your personal problems? Never	Felt confident about your ability to handle your personal problems? Almost never	Felt confident about your ability to handle your personal problems? Sometimes	Felt confident about your ability to handle your personal problems? Fairly often	Felt confident about your ability to handle your personal problems? Very often
Felt that things were going your way?	Felt that things were going your way? Never	Felt that things were going your way? Almost never	Felt that things were going your way? Sometimes	Felt that things were going your way? Fairly often	Felt that things were going your way? Very often

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* First Name

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* Last Name

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* Employee ID

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* Personal Email

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* Mobile Number

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* What is your preferred day to be contacted?

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* What is your preferred time to be contacted?

Please enter time in EST time zone.

Time

AM/PM

Client Care Hours:
Monday       8.00 am - 8.00   pm EST
Tuesday      8.00 am - 10.00 pm EST
Wednesday 8.00 am - 10.00 pm EST
Thursday     8.00 am - 10.00 pm EST
Friday         8.00 am - 6.00 pm EST