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Demographic Information

Just a few minutes of your time can make a big difference! Answer these short, anonymous questions and help us improve our information and support.

For MySelf For Someone Else

If you are taking this test for someone else, please use that person's information for the questions below.

About You

Your name

Your age

Gender*

Male

Female

Non Binary

Marital Status*

Single

Married

Divorced

Complicated

Who do you live with?*

Single

Family

Friends

Parents

Others

Occupation status*

Employed

Not employed

Freelancer

Entrepreneur

Other

Where are you from / ethnicity

Weight(KG)*

Height*

Do you any of the following habits or addictions?

Smoker

Alcoholic (Daily)

Substance Abuse (Marijuana, Cannabis, MDMA, LSD)

Any Other

About Your Mental Health

Have you ever received treatment/support for a mental health problem?

Yes No

Are you receiving treatment/support now?

Yes No

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Attached Treatment Report

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