Instruction (at the top of the form): Please answer the following questions honestly. Your responses will remain confidential and are intended to help identify if support or intervention may be needed. There was an error trying to submit your form. Please try again. Have you been feeling hopeless or worthless recently? * Yes No This field is required. Have you experienced a loss of interest in activities you once enjoyed? * Yes No This field is required. Do you feel like a burden to others? * Yes No This field is required. Have you had thoughts about ending your life? * Yes No This field is required. Have you talked or joked about death, dying, or suicide recently? * Yes No This field is required. Have you been withdrawing from friends, family, or social activities? * Yes No This field is required. Do you find it hard to sleep or eat properly for the past few days or weeks? * Yes No This field is required. Have you felt overwhelmed by guilt, shame, or emotional pain? * Yes No This field is required. Have you been using alcohol or drugs more than usual? * Yes No This field is required. Have you experienced sudden mood swings or extreme changes in behavior? * Yes No This field is required. Have you given away personal items or made arrangements as if preparing for something serious? * Yes No This field is required. Have you written a note, message, or post expressing thoughts of suicide or goodbye? * Yes No This field is required. Have you had a recent loss, trauma, or major life change (e.g., breakup, job loss, grief)? * Yes No This field is required. Would you like someone from our support team to reach out to you? Yes No Name * This field is required. Contact Number * This field is required. Submit There was an error trying to submit your form. Please try again.
