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MENTAL HEALTH SURVEY
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Mental Health Survey

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1. PERSONAL WELL BEING SURVEY

Initials*
Today's Date*
Select a Number between 1 and 10 to reflect how satisfied you are with these aspects of your life. 1 would be No Satisfaction at All and 10 would be Completely Satisfied.
12345678910
1. With your life as a whole?
2. With your standard of living?
3. With your health?
4. With what you are currently achieving in life?
5. With your personal relationships?
6. With how safe you feel?
7. With feeling part of your community?
8. With your future security?

2. MORALE INJURY SURVEY

MORALE INURY OUTCOME SCALE*
This questionnaire asks about experiences you may have had after a very stressful experience in which you: (A) did something (or failed to do something) that went against your moral code or values; or (B) you saw someone (or people) do something or fail to do something that went against your moral code or values; or (C) you were directly affected by someone doing something or failing to do something that went against your moral code or values (e.g., being betrayed by someone you trusted).
If yes, please check the type of experience that is most currently distressing:*
Keeping this experience in mind, please indicate how much you agree with the following statements in terms of the impact of this experience in the last month, by selecting one for each item below.
Strongly DisagreeDisagreeNeither Agree/DisagreeAgreeStrongly agree
1. I blame myself.
2. I have lost faith in humanity.
3. People would hate me if they really knew me.
4. I have trouble seeing goodness in others.
5. People don’t deserve second chances.
6. I am disgusted by what happened.
7. I feel like I don’t deserve a good life.
8. I keep myself from having success.
9. I no longer believe there is a higher power.
10. I lost trust in others.
11. I am angry all the time.
12. I am not the good person I thought I was.
13. I have lost pride in myself.
14. I cannot be honest with other people.
How much has this experience made it hard for you to function in each of the following areas? Select one number for each item below? 0 is NOT AT ALL, 3 would be SOMEWHAT and 6 would be EXTREMELY. If an area is not applicable, select N/A**.
0123456N/A
1. Romantic relationships with spouse or partner.
2. Relationships with your children.
3. Relationships with other family members.
4. Friendships or socialising.
5. Work.
6. Training or education.
7. Day to day activities, such as chores, errands, managing medical care.
8. Religious faith/spirituality.

Thank You

*The Moral Injury Outcome Scale (2021). Litz, B.T., Phelps, A., Frankfurt, S., Murphy, D. Nazarov, A. Houle, S., Levi-Belz, Y., Zerach, G., Dell, L., Hosseiny, F., and the members of the Moral Injury Outcome Scale (MIOS) Consortium. MIOS consortium activities were supported in part by VA Cooperative Studies Program, Office of Research and Development, US Department of Veterans Affairs; Department of Veterans’ Affairs Australia, Phoenix Australia - Centre for Posttraumatic Mental Health; and the Canadian Centre of Excellence on PTSD and Related Mental Health Conditions. **The Brief Inventory of Psychosocial Functioning (Kleiman et al., 2020).
Email*
Please fill out your email address for a copy of your form.