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That Zen Life Wellness Foundation, Inc.

***Important Notice***

This wellness check form is monitored during normal business hours and is not intended for emergencies.

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If you or someone else is in immediate danger or experiencing a medical emergency, call 911 immediately.

If you are having thoughts of suicide, experiencing a mental health crisis, or need immediate emotional support, Call or text 988 to reach the Suicide & Crisis Lifeline, available 24 hours a day, 7 days a week.

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If your situation is not an emergency, please complete this form and a Peer Recovery Specialist from That Zen Life Wellness Foundation will contact you as soon as possible.

City of Residence
Chesapeake
Franklin
Hampton
Newport News
Norfolk
Portsmouth
Southampton
Suffolk
Virginia Beach
Other
I am a:

In the last 30 Days:

Have you wished you were dead or could go to sleep and not wake up?
Yes
No
Have you had any actual thoughts of killing yourself?
Yes
No
Have you had six or more drinks on one occasion?
Yes
No
Have you had thoughts of wanting to stop drinking alcohol or using drugs?
Yes
No
Do you often feel down, depressed, or hopeless?
Yes
No
Have you been unable to stop or control your worrying?
Yes
No
Do you have trouble participating in self-care?
Yes
No

IF YES TO QUESTION 2, 3, AND 5 ANSWER QUESTIONS 8, 9, AND 10

Have you been thinking about how you might harm yourself?
Yes
No
N/A
Have you blacked out and were unable to remember key events from the night before?
Yes
No
N/A
Do you have trouble getting out of bed in the morning?
Yes
No
N/A
Risk Level
Contact Info
Check all that Apply:
I would like Services for:
Myself
Family Member
No Services
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