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Mental Wellness Consultation
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Email *
Name *
Job Title
The industry you work in *
Phone number *
On a scale of 1 to 10, how would you rate your current stress level? 1 - No Stress, 5 - Moderate, 10 - Extremely *
What are you seeking help with? *
Please briefly describe how it is impacting your work and life? *
What have you tried to help with things? *
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How much time and effort have you invested to improve your situation? *
How much have you currently invested to try to help your situation?
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If it was 6 months from now, what would your life be like if this issue was resolved? *
How do you best learning new things? (Select all that apply) *
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Comments:  What else would be important for us to know about you?
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