Solera Health Application (2025-04-06)

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Please enter a valid cell phone numberFormat: (000) 000-0000.

College Email (.edu)

example@example.edu

Are you a College Senior?

Which School?

Enter name of the College where you are a Senior

LinkedIn Profile:

linkedin.com/in/xxxxx/

Rate your comfort with technology on a scale of 1 to 10 where:

1 Novice: minimal experience with desktop tools, require frequent assistance
5 Proficient: comfortable using a wide range of desktop tools and features
10 Expert/Power User: master desktop tools; customize, automate, or optimize workflows

Comfort with technology:

Rate your anxiety level on a scale of 1 to 10:

1 Anxiety Free: no anxiety or worry at all
5 Moderate Anxiety: frequent worrying, tense muscles, hard time focusing
10 High Anxiety: anxiety is hard to manage, impairs ability to function or think clearly

Anxiety level:

What are you hoping to get out of trying a new approach to anxiety?

Sender Name:

Reply-to Email:

example@example.com