1. 性别/ Gender ：__________ 学号/ Student ID ：_____________
2. 18-22岁 23-25岁 26-30岁 30岁以上/Over 30
3. 亚洲国家/Asian Country 欧洲国家/European Country 非洲国家/African Country 美洲国家/American Country
4. 来华时长/ Length of stay in China
3个月-6个月（初步适应阶段）3months -6months 6个月-1年（适应中期）6months -1year 1-2年（基本适应）1-2 years 2年以上（完全适应或长期居留）Over 2 years (Fully adapted or long-term residence)
5. 教育层次/ Education Level 本科生 / Undergraduate 硕士研究生 / Master’s Student 博士研究生 / Doctoral Student 语言进修生 / Visiting Student
6. 中文水平/ Chinese Proficiency HSK Level 1-2 (Basic) HSK Level 3-4 (Intermediate) HSK Level 5-6 (Advanced)
7. 校内留学生公寓/School International Student Apartment 校外租房/Renting Off-Campus 其他/Other
8. 主要社交对象/ Main Social Objects
本国留学生/Students from the Same Country 其他国家留学生/Students from Other Countries 中国学生/Chinese Students 混合社交（以上均有）/Mixed Socialization (all of the above) 很少社交/Rarely Socialize
指导语/Instruction： 请勾选所有让你感到困扰、进而产生心理压力、焦虑或低落情绪的方面，可多选；若有以下未提及的困扰，请在“其他”中详细填写，以便我们全面了解。 Please check all the aspects that make you feel troubled, and then cause psychological pressure, anxiety or low mood. Multiple choices are allowed; if there are distresses not mentioned below, please fill in details in "Other" to help us understand comprehensively.
9. 听不懂中文授课 unable to understand Chinese classes 不会用中文表达想法 unable to express ideas in Chinese 日常沟通不畅 poor daily communication 阅读中文材料困难 difficulty reading Chinese materials 中文考试压力 pressure from Chinese Level exams other
10. 课程难度超出预期 course difficulty exceeds expectations 考试形式与本国差异大 exam form is quite different from that in your own country, 作业量大且截止时间紧 too many assignments with tight deadlines 与导师/任课教师沟通不畅 poor communication with supervisors/teachers 专业学习目标不明确 unclear professional learning goals 担心挂科或毕不了业 worrying about failing exams or not graduating Other
11. 不适应中国饮食口味和饮食习惯 unadapted to Chinese food taste and eating habits 气候不适应导致身体不适 physical discomfort caused by unadapted climate 住宿条件不符合预期 accommodation conditions not meeting expectations 交通出行不便利 inconvenient transportation 就医流程不熟悉且语言不通 unfamiliar medical procedures and language barriers 网购/支付等日常操作困难 difficulty in daily operations such as online shopping/payment Other
12. 不理解中国的传统文化、节日习俗和社交礼仪 unable to understand Chinese traditional culture, festival customs and social etiquette 中国和你的国家的价值观和思维方式差异大 Major cultural and cognitive differences between China and your home country 难以融入中国社会和校园文化 difficult to integrate into Chinese society and campus culture 因文化差异被误解或排斥 being misunderstood or excluded due to cultural differences 长期远离家乡和亲人，思乡情绪强烈 Long-term separation from hometown and relatives, strong homesickness Other
13. 没有知心朋友、长期感到孤独 no close friends, feeling lonely for a long time 与室友/同学相处产生矛盾 conflicts with roommates/classmates 难以与中国学生建立友谊 difficult to establish friendships with Chinese students 不敢主动社交、被孤立或排挤 dare not take the initiative to socialize, being isolated or excluded Other
14. 事务 方面/ Affairs
签证、居留许可办理流程繁琐、材料准备复杂、担心手续出错影响停留 cumbersome visa and residence permit application procedures, complex document preparation, worrying about procedure errors affecting stay 不熟悉中国法律法规和学校校规校纪、担心不小心违规受处分 unfamiliar with Chinese laws, regulations and school rules, worrying about being punished for accidental violations Other
15. 生活费、学费压力大 high pressure of living expenses and tuition fees 家庭经济支持不足 insufficient family financial support 无法兼职赚钱 unable to take part-time jobs to earn money 兑换货币不方便 inconvenient currency exchange Other
16. 想念家人和家乡 missing family and hometown 难以适应独处生活 difficult to adapt to living alone 异国他乡缺乏归属感 ack of sense of belonging in a foreign country 节日期间情绪低落 low mood during festivals 无法随时与家人联系 unable to contact family at any time Other
17. 其他（请详细填写，如心理本身敏感、学业与生活平衡困难等）/Other: (Please fill in details, such as inherent psychological sensitivity, difficulty in balancing study and life, etc.)
指导语/Instruction ：针对你上面勾选的困扰方面，请分别评价每类困扰给你带来的心理压力、焦虑或低落程度（未勾选的可直接跳过，无需填写）；评价时请结合自身实际感受，不要刻意夸大或缩小。
For the distressed aspects you checked above, please evaluate the degree of psychological pressure, anxiety or depression brought by each type of distress (you can skip those not checked directly); when evaluating, please combine your actual feelings and do not deliberately exaggerate or downplay.
选项/Options ：
1=轻微困扰（几乎不影响心情，偶尔出现，很快能缓解）/Mild distress (hardly affects mood, occurs occasionally, and can be relieved quickly)
2=中度困扰（偶尔影响心情和学习生活，需要一定时间调整才能缓解）/ Moderate distress (occasionally affects mood, study and life, and needs a certain time to adjust to relieve)
3=较严重困扰（经常影响心情和学习生活，调整后仍难以缓解，产生明显焦虑/低落）/Severe distress (often affects mood, study and life, difficult to relieve even after adjustment, resulting in obvious anxiety/depression)
4=极度困扰（严重影响正常学习生活，长期处于焦虑/低落状态，无法自行调整）/Extreme distress (seriously affects normal study and life, in a state of anxiety/depression for a long time, unable to adjust by oneself)
18. 语言方面困扰程度/ Degree of language distress
1 2 3 4
19. 学习方面困扰程度/ Degree of study distress
1 2 3 4
20. 生活方面困扰程度/ Degree of life distress
1 2 3 4
21. 文化方面困扰程度/ Degree of cultural distress
1 2 3 4
22. 人际方面困扰程度/ Degree of interpersonal distress
1 2 3 4
23. 事务方面困扰程度/ Degree of affairs distress
1 2 3 4
24. 经济方面困扰程度/ Degree of economic distress
1 2 3 4
25. 思乡方面困扰程度/ Degree of homesickness distress
1 2 3 4
26. 其他困扰程度/ Degree of other distress
1 2 3 4
27. 这些困扰是否让你产生过焦虑、低落或其他负面情绪？/ Have these distresses made you feel anxious, depressed or other negative emotions?
从未/Never（几乎没有因困扰产生负面情绪） 偶尔/Occasionally（偶尔产生，很快能缓解） 经常/Often（经常产生，影响日常状态） 总是/Always（长期处于负面情绪中，难以自拔）
28. 负面情绪对你的影响主要体现在哪些方面？（可多选）/ In which aspects do negative emotions mainly affect you? (Multiple choices allowed)
学习效率下降/Decreased learning efficiency 睡眠质量变差/Poor sleep quality 食欲变化（下降或暴饮暴食）/Appetite changes (decreased or overeating) 不愿与人交流/Unwilling to communicate with others 对任何事情提不起兴趣/Lack of interest in anything Other
29. 你是否愿意向老师倾诉这些困扰、寻求帮助？/ Are you willing to talk to teachers about these distresses and seek help?
非常愿意/Very willing（主动想倾诉，希望得到老师帮助） 愿意，但不知道如何开口/Willing, but don’t know how to start 不确定/Uncertain 不愿意/Unwilling
30. 你希望老师为你提供哪些具体帮助？（可补充，越详细越好）/ What specific help do you hope teachers can provide for you? (Can supplement, the more detailed the better)