Mental Inventory and Emotional Assessment

This brief mental health screening is non-commercial. It is designed to determine your psychological well-being and identify areas for further evaluation or treatment. All questions reflect the respondents entire life. This assessment is self-scored.

What is your first and last name?

_____________________________________________

What is your age? (Multiple may apply)

☐ 0-18

☐ 19-25

☐ 26-35

☐ 36-50

☐ 50+

☐ You were a child yesterday

What is your gender? (None may apply)

☐ Man

☐ Woman

☐ Non-binary

☐ Your father’s daughter

☐ You prefer not to say

What is your current location? (Multiple may apply)

☐ Your bedroom

☐ Your bathroom floor

☐ Your childhood home

☐ Inside your body

☐ Outside your body

Answer this section to the best of your ability or not at all. If you begin to experience discomfort, call someone who loves you.

Beware of the subjective nature of self-reporting and the limited scope that may not capture all relevant factors.

Check all that apply:

☐ You often feel lonely

☐ You have trouble falling asleep

☐ You often feel a sense of doom

☐ You find it difficult to cope with memories of the past

☐ You don’t understand your purpose in life

Check all that apply:

☐ Your chest beats dull and irregular

☐ You wish you were stronger

☐ You always thought you’d wake up different

☐ You tell yourself your own life story

☐ You photograph yourself in the mirror

☐ You wander aimlessly through the night

Check all that apply:

☐ Your friends are worried about you

☐ Your vision is compromised

☐ You experience a kind of blindness that makes smoke and fog look the same

☐ Upon smelling smoke, your first thought is that your house is burning down

☐ In a dream where everyone you know dies, your feet are concrete blocks

☐ You believe you may die at any point

☐ You may die at any point

Check all that apply:

☐ You remember a story of a chimp speaking to its baby in sign language

☐ You speak in the language of your captor

☐ You speak, but the bar of a cage comes directly out of your throat

☐ You look down to find your hands

☐ You discover only roadkill

☐ You are a motherless child

Check all that apply:

☐ You think if you tattoo ‘God Fearing’ on your face, you may be spared from some type of agony

☐ You have been warned about emotional amputation

☐ You buy an axe

Check all that apply:

☐ You want to call the doctor but can’t find the number

☐ You want to call out to the doctor but the receiver buzzes empty, moths behind a curtain

☐ Doctor calls past midnight, but like in a dream you open your mouth to speak and a train track of nothing splits your tired jaws in two

☐ Please check this box to call out for help

☐ Check this box

☐ Please