Wellbeing support Assessment Form 🧠✨
Please provide your details and describe your concerns to help us understand your needs.
This space offers wellbeing support on your journey to healing and is not professional support or counseling. I am currently pursuing a dual Master’s in Clinical Mental Health Counseling and School Counseling, and this space is here to support healing, reflection, and breaking patterns.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Concerns (What brings you to seek support?)
*
How long have you been experiencing these concerns?
Have you accessed professional support before? (e.g., therapist, counselor, etc.)
Yes
No
If yes, please briefly describe your previous professional support experience.
Are you currently taking any medication for mental health?
Yes
No
If yes, please list the medications.
Please indicate any current symptoms you are experiencing.
Anxiety
Depression
Stress
Sleep Issues
Relationship Difficulties
Other
What are your goals for support?
*
Do you have a support system (family, friends, etc.)?
Yes
No
Is there anything else you would like us to know?
Preferred payment method
Venmo
Cash App
PayPal
Apple Pay
Other
Submit Assessment
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