General Mental Health

1

To begin, tell us why you're looking for support today.* This field is required.

I’m feeling anxious

I’m feeling down or depressed

I’m struggling with relationship challenges

I’ve experienced trauma (past or present)

I’m overwhelmed by stress at home or work

I’m having trouble sleeping

Something else

3

How long have you been feeling this way?* This field is required.

Less than a month

1–3 months

3–6 months

More than 6 months

4

Are there specific areas you’d like to work on in therapy?* This field is required.

Managing emotions

Building self-confidence

Stress management

Processing trauma

Developing coping strategies

Something else

5

What specific areas would you like to focus on in therapy? (Select all that apply)* This field is required.

Managing emotions

Building self-confidence

Stress management

Processing trauma

Developing coping strategies

Other

6

Have you been to therapy before?* This field is required.

Yes

No

7

Full Name* This field is required.

First Name

Last Name

8

Date of Birth* This field is required.

Date

9

Phone Number* This field is required.

Please enter a valid phone number.

10

Email* This field is required.

example@example.com

11

In which state are you currently residing?* This field is required.