Intake form

Help us serve you better

Name *

Email address *

What is your age range?

What services are you interested in?

Please select at least one option.

Individual therapy

Couples therapy

Group therapy

Corporate wellness programs

Workshops and seminars

How did you hear about us?

What are your primary concerns or areas of focus?

Have you previously engaged in therapy or counseling?

What is your preferred method of communication?

Please select at least one option.

In-person

Video call

Phone call

Are you currently taking any medications related to mental health?

Do you have any specific goals for therapy?

What is your availability for sessions?

Additional questions or comments

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The Mind Hub Studio