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Serene Mind Counseling Services
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Intake form
Help us serve you better
Name
*
Email address
*
What are your primary concerns?
Please select at least one option.
Anxiety
Depression
Relationship issues
Stress management
Trauma
Self-esteem
Life transitions
Grief
What type of counseling are you seeking?
Select
Individual Counseling
Couples Counseling
Family Counseling
Group Counseling
Teletherapy
In-Person Counseling
How did you hear about us?
Select
Referral
Search Engine
Social Media
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What is your preferred method of contact?
Please select at least one option.
Email
Phone
Text message
What is your age range?
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and over
Do you have any specific goals for counseling?
Which service or services are you interested in?
Please select at least one option.
Individual counseling
Couples therapy
Court mandated treatment
LPC pre-licensure supervision
LPC consultation services
Additional questions or comments
Submit
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