Check-In Form
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Select your age range
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Please Select
12–17
18–24
25–34
35–44
45–54
55–64
65–74
75 and older
Who do you have an appointment with today ?
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Rea Recreations
Love The Stylist
Diamond Lakim Hair
Krownee By Diamond Lashes
Sovereign Belle Beauty
Solo Kutz
Did you know we offer Beauty and Mental Health Services ?
Inner and Outer Glow is a one stop shop Our Salon is here to connect you with professionals that promote internal and external beauty .Our mental health affects how we think, feel, and handle life’s challenges. Whether you're facing anxiety, depression, or just need support, we’re here to help. Your information is confidential and allows us to tailor your care.
Have you previously received therapy or counseling?
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Please Select
YES
NO
Please Specify: If yes, when and for what reason?
Have you ever been diagnosed with a mental health condition?
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Yes
No
Please Specify: If yes, when and for what condition?
Current Mental Health Status
This is a safe and secure form ,your response help us understand your needs and facilitates with next steps .There are no right or wrong answers, please answer all questions honestly .
How would you rate your current mental health on a scale of 1-10? (1 = Very Poor, 10 = Excellent)
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1 -4 Very poor
5 -7 Up and down
8-10 - Excellent
How would you rate your current anxiety level?
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Score 0-4: Minimal
Score 5-9: Mild
Score 10-14: Moderate
Score greater than 15: Severe
What are the main concerns you're facing that you feel may benefit from therapy? (Check all that apply)
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Anxiety
Depression
Stress
Trauma/PTSD
OCD
Relationship Issues
Self-esteem Issues
Substance Use
Suicidal Thoughts
None of the Above
How often do you experience the following?
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Please Select
Sometimes
Often
Always
Emotional and Behavioral Assessment
Emotional and behavioral assessments help us understand how you’re coping with life’s challenges. By sharing this information, we can tailor our approach to best meet your needs and help you feel heard and supported. Your responses are confidential and vital in guiding your path to better well-being.
How do you currently cope with stress or emotional difficulties?
Exercise
Talking to friends/family
Therapy/Counseling
Substance use
other (please specify)
Please Specify:
In the last 48 hours have you had thoughts to harm yourself or others?
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Please Select
Yes
No
Please Specify:
Do you struggle with substance use (alcohol, drugs, prescription misuse)?
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Please Select
Yes
No
Please Specify:
Lifestyle & Social Support
Your lifestyle and support system can often contribute to your mental well-being. Recognizing your strengthens and challenges can help you make positive changes and build a stronger foundation for your mental health. Your mental health matters. There are no right or wrong answers—just your journey.
How would you describe your overall physical health?
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Excellent
Good
Fair
Poor
Do you have any major life stressors currently affecting you?
*
Job loss
Financial struggles
Family issues
Grief
Limited Family Support
None of the above
Other
How would you describe your support system?
Please Select
Strong
Moderate
Weak
None
Next Steps
We are dedicated to supporting your mental well-being every step of the way. Our team is here to provide a safe space where you can explore your feelings, gain insights, and develop strategies for managing life’s challenges. We're committed to helping you feel heard, supported, and empowered on your journey to mental wellness.
Are you ready to take the next step in your mental health journey?
*
Yes
No
Would you like to move forward with a therapy consultation ?
*
Yes
No
Do you have a preference for therapy format?
In-Person
Virtual
No Preference
Do you have a preference when choosing the ideal professional for your needs ?
Please Select
Male Therapist
Female Therapist
What do you hope to achieve through therapy?
Please give reference of any two people whom you feel could benefit from therapy or counseling :
Full Name
Contact Number
1
2
Suggestions/ feedback if any for further improvement:
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