JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Contact information
Mental Wellness Consultation
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Job Title
Your answer
The industry you work in
*
Your answer
Phone number
*
Your answer
On a scale of 1 to 10, how would you rate your current stress level? 1 - No Stress, 5 - Moderate, 10 - Extremely
*
1
2
3
4
5
6
7
8
9
10
What are you seeking help with?
*
Your answer
Please briefly describe how it is impacting your work and life?
*
Your answer
What have you tried to help with things?
*
Exercise
More sleep
Talking with a family member or friend
Talking with a colleague
Therapy
Enrolled in a course or workshop
Reading books or articles
Other:
Required
How much time and effort have you invested to improve your situation?
*
3 months
6 months
12 months
As long as it takes
How much have you currently invested to try to help your situation?
under $100
$100 - $499
$499 - $999
over $1000
Clear selection
If it was 6 months from now, what would your life be like if this issue was resolved?
*
Your answer
How do you best learning new things? (Select all that apply)
*
Working with someone 1 on 1
Working in a group setting
Reading books
Taking online course
In person training/workshops
Watching videos
Listening to podcasts
Other:
Required
Comments: What else would be important for us to know about you?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
