Intake form

Name *

Email address *

What age group do you belong to?

What is your primary mental health concern?

Please select at least one option.

Anxiety

Depression

Stress

Relationship Issues

Self-esteem

Trauma

How would you describe your current mental state?

Please select at least one option.

Stable

Fluctuating

Unstable

Improving

Deteriorating

Have you previously sought help for your mental health?

What methods of assistance are you interested in?

Please select at least one option.

Chatbot support

Guided meditation

Cognitive behavioural therapy

Mindfulness exercises

Journaling prompts

Peer support groups

How often do you experience mental health challenges?

What is your preferred method of communication?

Do you have any specific goals you want to achieve regarding your mental health?

Which service or services are you interested in?

Please select at least one option.

Mood tracking applications

Exercise

Meditation regularly is a great tool to settle, calm and clear the mind, enabling focus return.

ChatGPT

AI-Powered therapy chatbots

Personalized mental health insights

Alternative therapies

Additional questions or comments

MindAI