Request for Mental Health Coach Name Email Mobile Number Gender Male Female Work Status Employed Unemployed Student Preferred Contact method Email Phone Text Message 1. How would you rate your current mental health? Excellent Good Fair Poor Very Poor 2. What are your primary mental health concerns? Anxiety Depression Stress Relationship Issues Career Issues Self-Esteem Trauma 3. Are you currently receiving any mental health treatment? YES NO 4. What are your goals for working with a mental health coach? (Select all that apply) Improve Emotional Health, Manage Stress Overcome Anxiety Boost Self-Esteem Achieve Work-Life Balance Enhance Relationships 5. Do you have a preference for the type of coaching sessions? In-Person Online (chat) Phone Call 6. Preferred Days for Coaching Sessions Monday, Tuesday Wednesday Thursday Friday Saturday Sunday 7. How did you hear about SERCUE? Friend/Family Social Media Search Engine Advertisement 8. Is there anything else you'd like us to know about your situation or preferences? Consent I agree to the terms and conditions and consent to the collection and use of my personal information as outlined in the Privacy Policy. Send
