Q1. Assuming the individual has a mental health disorder, how often does he/she feel that it interferes with his/her work when not being treated effectively? (i.e. experience symptoms)

Not applicable to him/her Never Rarely Sometimes Often

Q2. Has the individual ever been diagnosed with a mental health disorder?

Yes No

Q3. Assuming the individual has a mental health disorder, how often does he/she feel that it interferes with his/her work when being treated effectively?

Not applicable to him/her Never Rarely Sometimes Often

Q4. Does the individual currently have a mental health disorder?

Yes Maybe No

Q5. Does the individual have a family history of mental illness?

Yes No Unsure

Q6. Did the individual have a mental health disorder in the past?

Yes Maybe No

Q7. Does the individual know of the options for mental health care available under his/her employer health coverage?

Yes No

Q8. How willing would the individual be to share with his/her friends & family that he/she has a mental illness?

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