Therapy Assistance Form
Thank you for taking the time to complete our questionnaire. Your responses will help us better understand your needs and preferences for therapy, enabling us to provide personalized support tailored to your emotional state and goals. Please be assured that all information you provide is completely confidential and will only be used for therapy purposes. We are committed to supporting you on your mental health journey with care and respect.
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Email *

On a scale of 1 to 5, how often have you been feeling overwhelmed or stressed recently?

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Rarely
Often

Rate your level of anxiety on a scale of 1 to 5 in the past week.

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Very Low
Very High

How would you rate your overall mood over the past month?

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Very Low
Very High

Rate your level of motivation and energy on a scale of 1 to 5 recently.

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Very Low
Very High

On a scale of 1 to 5, how well have you been sleeping lately?

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Poorly
Very Well
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