Name * First Name Last Name Email * Phone (###) ### #### How did you hear about me? * When it comes to mental health, what are you struggling with the most? (Feeling misunderstood, anxious, overwhelmed etc.) * What brings you into therapy now? (Break up, relationship issues etc.) * What have you tried to alleviate these challenges? Have you been to therapy before? * Why is it important to resolve these issues? (Worried it's going to impact my relationships, jobs; I'll feel lost etc.) * In terms of therapy is there anything specific you are looking for? (CBT, a therapist who is culturally competent etc.) * How committed are you to resolving these issues? (1 star - not at all committed to 5 stars - 110% committed) * 1 - Not at all committed 2 - Slightly committed 3 - Moderately committed 4 - Very committed 5 - Extremely committed Thank you!