Intake form

Name *

Email address *

What is your age range?

What is your gender?

What are your primary reasons for seeking support?

Please select at least one option.

Anxiety

Depression

Stress management

Relationship issues

Self-esteem

Work-related stress

How would you describe your current mental health status?

Have you previously sought therapy or counseling?

If yes, what type of therapy did you find helpful?

Please select at least one option.

Cognitive Behavioral Therapy (CBT)

Psychodynamic Therapy

Humanistic Therapy

Group Therapy

What type of support are you looking for?

Please select at least one option.

Individual therapy

Group therapy

Self-help resources

Community support

Mood tracking

How did you hear about avatar mind guide?

Additional questions or comments

Avatar Mind Guide