WellMiss Interest Form (HIPAA-Compliant)

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We’re honored that you’re considering WellMiss as part of your healing journey.

This short, secure form helps us understand how to best support you. You only need to share what feels comfortable.

Once submitted, a member of our care team will reach out to connect with you, answer any questions, and help you explore next steps.

All information shared is confidential and protected. If you need support while completing this form, please contact us at amandak@hellowellmiss.com.

Full Name *

Date of Birth
*

YYYY

Phone Number
*

Email Address *

Which state do you live in? *

What is your preferred method of contact? *

Phone Call

Text Message

Any

I consent to receive SMS, phone, and email outreach from WellMiss. A Care Coordinator will reach out to me directly. Message and data rates may apply. I may opt out of text messages at any time by replying STOP to any message received.

Yes

Required

What brings you to WellMiss at this time?

(Select all that apply)

I’ve experienced a traumatic event

I’m navigating grief or loss

I’m feeling overwhelmed, anxious, or emotionally distressed

I’m dealing with ongoing life stress or major life changes

I was referred by a provider or organization

I’m looking for support but not sure where to start

Other:

Required

If you feel comfortable, please share the type of experience(s) you’ve gone through:
(Optional — Select all that apply) *

Sexual Assault

Physical Assault or Battery

Dating Violence/Stalking

Domestic Violence or Intimate Partner Violence

Human Trafficking

Secondary Traumatic Stress

Homicide Loss (family/friend)

Child Loss/Stillbirth Loss

Miscarriage Loss

Suicide Loss

Overdose Loss

Mass Violence Loss

DUI/ DUID Loss

Unexpected or Sudden Loss

Traumatic Brain Injury or Head Trauma

Prefer not to answer at this time

Required

Which of the following are you currently experiencing?
(Optional — Select all that apply) *

Anxiety

Depression

Grief

Panic Attacks

Post Traumatic Stress Disorder (PTSD)

Excessive Sadness

Sleep Issues

Weight Gain/Weight Loss

Emotional Eating and/or Digestive Issues

Chronic Pain (Such as Fibromyalgia)

Broken Heart Syndrome

Hypertension

Cardiovascular Issues

Brain Fog and Migraines

Traumatic Brain Injury or Possible Head Trauma

Lack of Self Care

Lack of Self, Spirit, and Purpose

People Pleasing and Difficulty Setting Boundaries

Other:

Required

Trauma affects the mind, body, and overall well-being. Are you open to receiving support around healing?

Yes

Clear selection

What would you like support with right now?

I’d like to speak with someone to learn more about care options

I’m ready to begin care and would like help getting started

I’m not sure yet and just exploring

Clear selection

How did you hear about WellMiss? *

Is there anything you’d like to share with us before we connect?

Submit

Clear form

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