Pembrooke NeuroWellness Center

Self Assessment

Take a brief depression screening and share your contact details so our team can follow up. This is not a diagnosis — it helps us understand how you have been feeling and how to reach you.

Confidential follow-up

Takes about 2–3 minutes

Call 301-453-6367

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Complete your self assessment

Required fields are marked with *. Please complete both steps before submitting.

Your contact information

So we can follow up with your results

First Name *

Last Name *

Email *

Phone *

Location (City/State or ZIP) *

Over the last 2 weeks

How often have you been bothered by any of the following problems?

Little interest or pleasure in doing things? *

Feeling down, depressed, or hopeless? *

Trouble falling or staying asleep, or sleeping too much? *

Feeling tired or having little energy? *

Poor appetite or overeating? *

Feel bad about yourself — or that you are a failure or have let yourself or your family down? *

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual? *

Trouble concentrating on things, such as reading the newspaper or watching television? *

Thoughts that you would be better off dead or of hurting yourself in some way? *

Please do not submit private medical details beyond these screening answers. This form is not for emergencies.

Crisis support: If you may harm yourself or someone else, call 911 or 988, or go to the nearest emergency department.

Schedule a Consultation

Self Assessment

Self Assessment

Complete your self assessment

PEMBROOKE NEUROWELLNESS CENTER

Self Assessment

Over the Last 2 Weeks, How Often Have You Been Bothered By Any of the Following Problems?

Schedule a Consultation

Your Healing Starts Here.

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Fax Number

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