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🌿 Therapy & Mental Wellness

Free Burnout Self-Check Template

Free burnout and emotional-exhaustion self-check — score exhaustion, cynicism and reduced accomplishment across work and caregiving, with an AI recovery report.

~6 min
3 dimensions
AI PDF Report
AI Consultant
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Quick answer

Free burnout and emotional-exhaustion self-check — score exhaustion, cynicism and reduced accomplishment across work and caregiving, with an AI recovery report.

Disclaimer: this page and its AI report are for self-reflection and process reference only. They do not constitute medical, psychological, financial, legal or safety advice. Consult a qualified professional when needed.

Methodology: items are a structural adaptation of widely used frameworks, not an official version; scoring is indicative, not diagnostic.

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About this template

Burnout has three faces — exhaustion, cynicism and a shrinking sense of accomplishment — and recovery differs by which dominates. This three-dimension check adapts the classic Maslach framing with its own wording, and the AI report names the leading dimension with recovery prompts. Useful for occupational clients and caregivers alike.

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Live Preview

Sample form and AI report preview (fillable once the app is published).

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Fill it in to see how responses flow.
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Sample AI report with scoring visuals and recommendations, printable as a PDF.
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Scan the QR on the report to start an AI consultant chat.
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What's Included

The exhaustion, cynicism and efficacy items it scores.

1

Three classic dimensions

Exhaustion, cynicism and accomplishment scored separately.

2

Role-adaptive wording

Swap between work and caregiving contexts.

3

AI recovery report

Names the dominant dimension and what recovery typically starts with.

4

Escalation note

High exhaustion directs toward professional support.

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How It Works

From copy to a burnout signal in four steps.

1

Copy the template

Import the check with scoring and report — free.

2

Set the context

Edit role wording so it matches the actual population.

3

Complete privately

Six minutes on any device.

4

Act on the report

Start recovery work at the dominant dimension.

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Who Is This For

Who screens — staff, clinicians or practice owners watching load.

1

Therapists with occupational clients

Objectify the burnout conversation and track recovery.

2

Managers & team leads

Voluntary self-checks before people leave quietly.

3

Caregiver support programs

A screening frame that respects caregiving load.

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Key Features

What makes this burnout check actionable rather than just a score.

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Sample Questions Inside

The three-dimension exhaustion, cynicism and efficacy items — the live check scores each and suggests recovery entry points.

  1. I feel emotionally drained by my work or caregiving. (1-5)
  2. I have become less sympathetic since starting this role. (1-5)
  3. I feel I am not accomplishing anything meaningful anymore. (1-5)
  4. Weekends do not restore me anymore. (1-5)
  5. I worry about doing a poor job even when evidence says otherwise. (1-5)
  6. What would one less demand do for you right now? (open)
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Frequently Asked Questions

Is burnout a medical diagnosis?
No — in ICD frameworks burnout is described as an occupational phenomenon, not a medical condition; this check is self-reflection, and persistent exhaustion deserves a conversation with a professional.
Which of the three dimensions matters most?
There is no single answer — exhaustion predicts withdrawal fastest, but the report separates all three because recovery differs by dimension.
Is this the official Maslach Burnout Inventory?
No — the MBI is a licensed instrument; this is an original three-dimension check with its own wording, indicative rather than diagnostic.
Is it free to use?
Yes — copy the check, scoring and AI report into your FormLM workspace at no cost.
Can workplaces run it anonymously?
Yes — it works as an optional voluntary check; per-person clinical interpretation still belongs to professionals, not managers.
How often should someone retake it?
Monthly during a recovery plan; compare dimension trends rather than one-off totals.

Separate tired from burned out

A three-dimension burnout check with an AI recovery report — free to copy.