Age Range*

Choose one*

Sexual Orientation*

Marital Status*

Racial Background*

Are you Hispanic/Latino?

Household Size*

Household Income Range*

Did you grow up in or are you currently living in a home affected by hoarding? *

Did you grow up in a low income household? *

Did you grow up and live in conditions including (food scarcity, no heat/lights, no running water, rodent/pest infestations etc) *

Were you raised primarily by your biological parents?*

As a child did you spend any time in the foster care system? *

As a child did you struggle academically in school? *

What is the highest level of education that you achieved? *

Are you currently employed?*

What is the longest you have stayed at a job?*

Have you ever worked a job that you loved and the people were easy to work with?*

Have you ever been incarcerated? *

Have you ever been homeless (meaning living in your car, in shelters or on the streets)? *

Did you serve in the military *

Were you ever deployed for combat?*

In the past month, how often have you felt overwhelmed or stressed? *

Do you find it difficult to manage emotions such as anger, sadness, or anxiety? *

How often do you feel socially isolated or lonely?*

How often do you have crying spells?*

How often do you feel inadequate?*

How often do you have outbursts of anger?*

How often do you feel rejected/unloved or like a burden?*

How often do you have nightmares?*

How often are you angered/triggered by people around you (family, coworkers etc)?*

How often do you eat in excess?*

How often do you eat fast food or highly processed foods?*

How often do you exercise?*

Do you have healthy relationships and a good support system?*

Do you get enough sleep on a regular basis?*

Do you go to the dentist regularly for cleanings and routing appointments?*

Do you go to the doctor for regular check ups and appointments?*

Are you being treated including taking medication for any type of physical health condition?*

Have you ever gone to a professional licensed counselor/therapist?*

Do you currently see a professional licensed counselor/therapist?*

Have you ever been diagnosed with a mental health disorder*

Do you take medication to treat a diagnosed mental health disorder?*

Have you ever received inpatient psychiatric care?*

Do you have a family history of mental health issues (i.e. schizophrenia, bipolar disorder, anxiety, major depressive disorder etc)?*

Have you ever struggled with drug and/or alcohol abuse?*

Have you ever gone to rehab for drug and/or alcohol abuse?*

Do you have a family history of drug and/or alcohol abuse?*

Have you ever sought spiritual guidance or participated in pastoral counseling?*

Do you actively engage in spiritual practices (e.g., prayer, meditation, worship)?*

Did you attend church as a child?*

Do you currently attend church?*

If so how often?*

How important is spirituality in your daily life? *

Do you feel that your faith or spiritual beliefs provide comfort during difficult times? *

Religious/Spiritual Affiliation*

Do you believe faith has a positive impact on mental health?*