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What’s been going on lately that made you decide to reach out?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Stress Indecision Motivation issues Other

What kind of support would feel most helpful for you right now?

(For example: individual therapy, support during a specific season, ongoing care, etc.)

Psychotherapy Medication Other Not sure

If you’re comfortable sharing, have you experienced any mental health challenges or support in the past?

(This can include therapy, diagnoses, big life events, or anything else that feels relevant.)

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

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