Mental Health Therapy Interest Form

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* 1. How did you hear about our mental health therapy services?

Online search

Social media

Friend or family

Healthcare provider

Other

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* 2. What type of mental health therapy are you most interested in?

Individual therapy

Group therapy

Couples therapy

Family therapy

Not sure

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* 3. Have you received mental health therapy before?

Yes

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* 4. What are the main issues you are seeking help for? (Select all that apply)

Anxiety

Depression

Stress

Relationship issues

Trauma

Other

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* 5. How comfortable are you with online therapy sessions?

Very comfortable

Somewhat comfortable

Neutral

Somewhat uncomfortable

Very uncomfortable

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* 6. What are your main goals or expectations from therapy?

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* 7. How soon are you looking to start therapy?

Immediately

Within a week

Within a month

Not sure

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* 8. Please provide your name

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* 9. Please provide your email address

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* 10. Please provide your telephone number

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* 11. Please provide your address

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* 12. Is there anything else you would like us to know?

If you or someone you love is in a crisis and need immediate assistance the National Suicide & Crisis Hotline can be reached by calling or texting 988. The 988 Lifeline is available 24/7/365 and the conversations are free and confidential.

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