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Intake form
Help us serve you better
Name
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Phone Number
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Email address
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Which services are you interested in?
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Please select at least one option.
Unmask – Practice real conversations and build confidence in social situations
In-Home Wellness Companion – Hands-on support with daily living from someone who shows up and cares
NeuroLearning – Learn how your brain learns best and unlock smarter study or work strategies
Mental Health Assessment Funnel – A gentle, guided check-in to understand your current state and support needs
Neuroplasticity for Habit Change – Rewire old patterns and build better ones with brain-based approaches
Not Sure Yet – I’d like help deciding
What are your current goals or challenges?
Do you have any current medical or mental health concerns you’d like us to be aware of
Have you worked with a therapist, coach, or wellness provider before?
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Please select at least one option.
Yes
No
What days are you generally available for sessions?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How did you hear about us?
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Social Media
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Are there any specific concerns or challenges you'd like to focus on?
If yes, please describe your previous experience.
Additional questions or comments
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