Welcome to Medivive
We commend you for taking this important step toward improving your mental health. This survey will help us better understand your needs and provide personalized care just for you. Remember, you’re not alone in this journey—your health is our priority, and we’re here to support you every step of the way!
Privacy and Confidentiality Statement
Your answers to this survey will be kept confidential and secure. Medivive follows all privacy laws to protect your information. Everything you share will only be used to help you, and no information will be shared with anyone else without your permission, unless required by law.
Consent for Data Use
By completing this survey, you are allowing us to collect and use your information to provide the best care possible. This information will be kept safe and will only be seen by people who are
here to help you.
Parental or Guardian Consent: Before taking this survey, please have a parent or guardian read and sign below to understand their role in supporting you.
- Name of Guardian: ___________________________
- Signature of Guardian: ___________________________
- Date: ___________________________
Emergency Intervention Clause
If we think that you might be in danger or if you want to hurt yourself or someone else, we may need to share your information with emergency services to keep everyone safe. This is very important, and we want to make sure everyone is safe.
Crisis Disclosure
If you’re feeling very upset or in a crisis, please ask for help right away by calling 911 or a local crisis hotline. This survey isn’t meant for immediate help, but we want you to know that support is always available.
Limitation of Liability Disclaimer
Medivive is not responsible for any problems that might happen because of using this survey. This survey helps us understand you better and does not replace talking to a doctor or mental health professional about your feelings or concerns.
Section 1: Personal Information
Thank you for sharing this information; it helps us understand you better!
- Full Name: __________________________________________
- Date of Birth: __________________________________________
- Gender: Male ☐ Female ☐ Non-Binary ☐ Prefer not to say ☐
- Living Situation:
Alone ☐ With Parent(s) ☐ With Guardian ☐ With Other Family ☐ - School: __________________________________________
- Email (if applicable): ____________________ | Phone Number (if applicable):____________________
Section 2: Main Concerns
It’s important for us to know what’s on your mind!
- What is your main concern about your feelings or mental health? (e.g., sadness,
anxiety, stress): __________________________________________ - How long have you been feeling this way?
__________________________________________ - On a scale from 1 to 10, how strong are your feelings about this?
Mild ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ Very Strong ☐ 10 - How often do your feelings affect your daily activities (school, friends, hobbies)?
Never ☐ Rarely ☐ Sometimes ☐ Often ☐ Always ☐
Section 3: Emotional Well-Being
Let’s check in on how you’ve been feeling!
- Have you felt nervous, anxious, or worried?
Not at all ☐ 1-2 Days ☐ Several Days ☐ Almost Every Day ☐ - Do you find it hard to enjoy things you usually like?
Not at all ☐ 1-2 Days ☐ Several Days ☐ Almost Every Day ☐ - Have you felt sad or empty?
Not at all ☐ 1-2 Days ☐ Several Days ☐ Almost Every Day ☐ - Are you worried about things more than usual?
Not at all ☐ 1-2 Days ☐ Several Days ☐ Almost Every Day ☐ - Have you felt angry or frustrated often?
Not at all ☐ 1-2 Days ☐ Several Days ☐ Almost Every Day ☐
Section 4: Relationships
Having good connections with others is really important!
- How would you describe your relationship with your parents/guardians?
Supportive ☐ Strained ☐ Neutral ☐ - How would you describe your friendships?
Close ☐ Strained ☐ Neutral ☐ - Do you feel supported by your friends and family?
Yes ☐ No ☐ Sometimes ☐ - How do you usually talk about your feelings with your friends or family?
Openly ☐ Rarely ☐ Never ☐ - Do you have friends or trusted adults you can talk to when you need help?
Yes ☐ No ☐
Section 5: Sleep Patterns
Getting enough rest is key to feeling good!
- How many hours of sleep do you usually get at night?
Less than 4 hours ☐ 4-6 hours ☐ 6-8 hours ☐ More than 8 hours ☐ - Do you have trouble falling asleep or staying asleep?
Yes ☐ No ☐ Sometimes ☐ - Do you wake up often during the night?
Yes ☐ No ☐ - Do you feel rested when you wake up?
Yes ☐ No ☐ Sometimes ☐
Section 6: Coping with Stress
It’s great to know how you deal with stress!
- How would you rate your stress levels?
Low ☐ Moderate ☐ High ☐ Overwhelming ☐ - What do you usually do to cope with stress? (Check all that apply)
Talk to Friends ☐ Exercise ☐ Read ☐ Listen to Music ☐ Other:____________________________ - Have you ever felt so upset that you hurt yourself?
Yes ☐ No ☐ - If yes, have you talked to someone about it?
Yes ☐ No ☐
Section 7: Substance Use
Being honest about substance use helps us support you better!
- Do you use alcohol or drugs to help with stress or feelings?
Yes ☐ No ☐ - If yes, how often do you use them?
Daily ☐ Weekly ☐ Occasionally ☐ Rarely ☐ - Have you ever felt that your use of these substances is a problem?
Yes ☐ No ☐
Section 8: Trauma History
Discussing trauma can be challenging, but it’s important for your healing.
- Have you experienced any traumatic events (physical, emotional, or otherwise)?
Yes ☐ No ☐ - Would you like to talk about these experiences with your provider?
Yes ☐ No ☐
Section 9: Safety and Support
Your safety matters to us—let’s talk about it!
- Have you thought about harming yourself or someone else?
Yes ☐ No ☐ - Do you have a plan in place for what to do if these thoughts come up?
Yes ☐ No ☐ - Is there someone you trust that you can talk to when you feel this way?
Yes ☐ No ☐
Section 10: Final Thoughts
Your input is valuable—let’s hear it!
1. Is there anything else you want to share about your feelings or mental health?
Feedback Mechanism
We want to improve our services for you!
1. After completing this survey, please share any feedback or thoughts about your experience with this survey:
Thank You for Your Participation!
Thank you for taking the time to complete this survey as part of your onboarding process with Medivive. Your responses will help us understand your needs and prepare for your consultation. If you have any questions about the survey or your mental health, please make a note of them and review them with your provider during your consultation.
We look forward to supporting you on your journey to better mental health!
Crisis Resources & Emergency Contacts
In case of a crisis, please contact:
