Intake form

Name *

Email address *

What is your age range?

What is your gender?

What is your current occupation?

What are your primary concerns regarding mental health?

Please select at least one option.

Anxiety

Depression

Stress management

Relationship issues

Self-esteem

Trauma

Have you previously sought help for mental health issues?

What types of support are you interested in?

Please select at least one option.

One-on-one counseling

Group therapy

Workshops

Online resources

Crisis intervention

How did you hear about us?

Do you have any specific goals for your mental health journey?

Which service or services are you interested in?

Please select at least one option.

General information

Mental health support

Community connections

Additional questions or comments

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