Mental Wellness Coaching Intake Form

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Thank you for having interest in our Mental Wellness Coaching. It is an online health and wellness coach is a certified guide who supports your whole self—mind, body, and spirit.

We will help you develop new skills, healthy habits, and coping mechanisms to empower you to improve your mental health. Coaches draw from clinically validated techniques – like cognitive behavioral (CBT) and SMART Goals – to help you with many different goals ranging from challenging negative thinking to improving relationships.

Sessions are flexible and designed to fit your unique rhythm and lifestyle. To get started, please fill out the confidential intake form below.

We will contact you once we process your intake form to schedule your free consultation.

Have questions or ideas? Reach out anytime at noteworthyresourcesalbany@gmail.com — we’re here to help.

You're not alone. Let’s begin this journey together.

Email *

Full Name (First, Last) *

What Capital Region county do you live in?

If outside of the Capital Region, in "other" state, your county and town.

Albany County

Columbia County

Greene County

Rensselaer County

Saratoga County

Schenectady County

Schoharie County

Warren County

Other:

Zip Code *

Your Age Range *

12 - 17 years old

18 - 23 years old

24 - 29 years old

30 - 35 years old

36 - 41 years old

42 - 47 years old

48 years old and older

Please check the following race that best describes you: *

Question Type

Arab/Middle Eastern

Asian

Black/Brown

Caucasian

Hispanic

Indigenous- North American

Indigenous -Hawaiian or Pacific Islander

Other:

Your ethnicity

Do you struggle with any of the following mental illness conditions: *

ADHD/ADD

Adult Child of Addiction or Dysfunctional Families

Agoraphobia

Anorexia nervosa

Antisocial personality disorder

Anxiety Disorders

Autism Spectrum Disorder (ASD)

Binge eating disorder

Bipolar disorder

Body dysmorphic disorder

Borderline personality disorder

Bulimia

Claustrophobia

Cyclothymia

Depression

Dissociative disorders

Eating disorders

Fabricated or induced illness

Generalized anxiety disorder (GAD)

Health anxiety

Hoarding disorder

Munchausen syndrome

Obsessive compulsive disorder (OCD)

Panic disorder

Personality disorder

Phobias

Postnatal depression

Postpartum psychosis

Post-traumatic stress disorder (PTSD)

Psychosis

Psychotic depression

Schizophrenia

Seasonal affective disorder (SAD)

Selective mutism

Skin picking disorder

Social anxiety (social phobia)

Stress

Substance Use Disorder

Trichotillomania (hair pulling disorder)

Required

What would you like us to assist you with? *

Manage stress, anxiety, and everyday overwhelm

Strengthen and nurture meaningful relationships

Navigate major life transitions with clarity and confidence

Improve the quality of your sleep and rest

Build emotional resilience and inner calm

Process grief and loss with compassion and support

Other:

Required

Which one do you most identify with? *

Adult or teen navigating stress or burnout

Parent seeking balance & better focus

Student or Professional looking for work-life harmony

Looking to improve their mental, emotional, or overall well-being can benefit

Other:

Required

What motivated you to seek our help? *

Seeking support for yourself

To increase my knowledge of mental illness and coping skills

I am in crisis

I don't know what to do to improve my mental and emotional well-being

Need support and ways to help manage my stress

Feeling stuck in unhealthy habits

Interested in learning ways to set and maintain healthy boundaries

Coping with burnout

Struggling with grief and loss

Simply working toward a healthier lifestyle

Struggling with my transition with being a new parent

Need help with emotional regulation and trauma responses

Other:

Required

In what ways can our mental wellness coach help you? Share a little bit more about what you would like to get from this program.

(Examples: What have you been going through lately? Any goals you have in mind to focus on? Any strategies or skills you would like to develop to better support what you are going through?)

Feel free to share any information with us that will help us better support your needs.

How did you hear about NWR's Mental Wellness Advocacy Program (MWAP)?
*

Family member

Friend

News Segment/Podcast Reference

Flyer

Social Media

Other:

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