Mental Health Survey
Please fill out this survey form for availing government provided mental health benefits
Name:
Email:
Age(optional):
What is your employment status?
(select one)
unemployed
self-employed
employed
retired
Disability status (required)
un-registered
registered
Diagnosed illnesses (check all that apply):
Schizophrenia
Obsessive-Compulsive Disorder
Bipolar Disorder
Social Anxiety Disorder
Clinical Depression
Post-Traumatic Stress Disorder
Other
If other, please specify: