Mental Health Therapy Interest Form Question Title * 1. How did you hear about our mental health therapy services? Online search Social media Friend or family Healthcare provider Other Question Title * 2. What type of mental health therapy are you most interested in? Individual therapy Group therapy Couples therapy Family therapy Not sure Question Title * 3. Have you received mental health therapy before? Yes No Question Title * 4. What are the main issues you are seeking help for? (Select all that apply) Anxiety Depression Stress Relationship issues Trauma Other Question Title * 5. How comfortable are you with online therapy sessions? Very comfortable Somewhat comfortable Neutral Somewhat uncomfortable Very uncomfortable Question Title * 6. What are your main goals or expectations from therapy? Question Title * 7. How soon are you looking to start therapy? Immediately Within a week Within a month Not sure Question Title * 8. Please provide your name Question Title * 9. Please provide your email address Question Title * 10. Please provide your telephone number Question Title * 11. Please provide your address Question Title * 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. Page1 / 1 100% of survey complete. Done
