MENTAL WELLBEING CHECK-IN QUESTIONNAIRE

Name: ___________________________________________________ Date: _____________________

Age: __________ Gender: ____________ Grade & Section: _________________________

1. How are you feeling today? The past few days?

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2. How was school lately? Relationship with classmates? With teachers? Other staff?
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3. How is your situation at home?

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4. Can you tell me about your relationship with your parents? Siblings?
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5. What do you consider are the stressors in your life currently?

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6. What do you usually do to cope with stress? Sadness?

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7. How is your sleep lately?

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8. What makes you worry lately?

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9. Do you have any medical condition? Are you taking any medication?
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10. Have you received mental health/psychological services before? If yes, what was the reason?
Have you been diagnosed?
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11. Do you have thoughts of hurting yourself? Did you ever hurt yourself? If yes, when was the last
time? What triggered you to do so?
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12. What do you see as your strengths?

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13. What do you look forward to? What are your future goals?
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14. What areas of your life would you like to improve? How do you think will you achieve this
improvement?
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