Name * First Name Last Name Email * Phone (###) ### #### Location/Address * Are you seeking services for individual family couple group Are you seeking mental health education or professional development services for a business or organization? If so, please provide the following: Name of company or organization Name of Contact Person Email of Contact Person Phone No. (including ext.): (###) ### #### Counseling and Coaching From the following list, please identify your primary concern: Emotional and Mental Wellness Goal Setting and Strategizing Relationship Help Psycho-education(mental health education) On a scale of 1 -5, rate how you cope with life stresses, 1 being not very well, and 5 being No problem at all: 1 2 3 4 5 If you are seeking individual services, use the same rating scale to state how open you are to reaching out for support. (scale of 1 -5) 1 2 3 4 5 Are you in need of: Exploration of past events Help getting unstuck Help transitioning from one life space to another (career change, divorce, empty nest etc.) Insight into your emotions, behaviors and thinking Mental Health Education on a specific topic Assistance navigating a family, team or other group situation Other Are you open to sharing your services with others exploring the same or similar goals? Yes No Corporate Consulting – Mental Health Education and Professional Development What category does your business/ organization fall into: Helping professionals Digital/ IT Consumer/Product Retail Hospitality Education Health and Wellness Organization and Management Non-profit Religious Government Other Describe the current work culture in your business or organization. For all services offered, would you prefer In-person Virtual Either On a scale from 1 – 5, rate your company’s effectiveness in the following areas: 1- Conflict Management 1 2 3 4 5 2- Team building 1 2 3 4 5 3- Motivation 1 2 3 4 5 4- Overall culture 1 2 3 4 5 Please rate your view of employee satisfaction 1- Conflict Management 1 2 3 4 5 2- Team building 1 2 3 4 5 3- Motivation 1 2 3 4 5 4- Overall culture 1 2 3 4 5 What challenges do you have or have you faced with your current department/business? Staff attendance Confronting toxic behavior Leadership lacks a human-centered approach, seeing employees as functions rather than people. X Supervision Please share any further information that can assist us in providing the highest quality services you may need. Thank you!
