What brings you here?

(What’s been on your mind lately?)

Anxiety / Stress Low mood / Depression Relationship concerns Work / career stress Grief or loss Self-esteem / identity Life transitions Trauma Family concerns Burnout Substance use and dependency

Current Wellbeing

(How have you been feeling recently?)

1 - Struggling a lot 2 - Not doing great 3 - Managing okay 4 - Mostly okay 5 - Doing well

How long have you been experiencing this?

A few weeks A few months 6+ months On and off for years

Therapy History

(Have you been to therapy before?)

No Yes

What Are You Hoping to Get From Therapy?

Therapist Fit (to help us match you better)

(What kind of support style would you prefer?)

Structured (tools, exercises, goal-oriented) Exploratory (open conversations, reflective) A mix of both Not sure

Practical Details

Online Phone In-person Weekday Morning Weekday Afternoon Evening Weekend

Safety Check (Important)

(Are you currently experiencing thoughts of harming yourself or feeling unsafe? )

No Yes

If yes: Please reach out to local emergency services or a crisis helpline. This form is not monitored for emergencies.

Anything else you’d like us to know before we speak?

How did u hear about us?

Instagram YouTube Referred by a friend Google Other

Consent

I understand this form is for inquiry purposes and not a substitute for emergency mental health support. Request Consultation