Form 1
Step
1
of
8
12%
Which service are you looking for?
(Required)
Team Therapy
Couples Therapy
Meditation
Fitness
Let’s start by taking care of yourself
What’s your current state of feeling?
(Required)
I am feeling anxious and panicky
Having Difficulty in relationship
A traumaic Experience
Trouble Sleeping
I am navigating addiction or difficulty with substance Abuse
Felling down and depressed
I am feeling with stress at work or school
Something else
How would you rate your sleeping habits?
(Required)
Excellent
Good
Fair
Poor
How would you rate your Physical health?
(Required)
Excellent
Good
Fair
Poor
What gender do you identify with?
(Required)
Male
Female
Transgender Male
Transgender Female
Gender Queer
Gender Variant
Other
Non Binary
What gender do you prefer in a provider?
(Required)
No Preferences
Female
Transgender Male
I am not sure
Gender Queer
Gender Variant
Other
Non Binary
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
What is your Date of Birth?
MM slash DD slash YYYY