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New Visitor Questionnaire
Blank Form (#4)
1. What brings you to our website today?
I'm looking for coaching/therapy services
I need help with stress and anxiety management
I want to improve my relationships
I'm exploring personal growth and self-development
I'm interested in mental wellness resources
Just browsing
2. Have you ever received coaching or therapy before?
Yes, I have experience with coaching/therapy
No, this is my first time
I've tried self-help resources but not professional coaching
3. What areas of life are you looking to improve? (Select all that apply)
Mental & Emotional Well-being (Stress, Anxiety, Depression)
Personal Growth & Self-Awareness
Relationships & Marriage Counseling
Career & Work-Life Balance
Confidence & Self-Esteem
Weight Management & Body Image
Trauma Healing & Past Experiences
4. What type of service are you looking for?
One-on-One Coaching/Therapy Sessions
Group Therapy & Workshops
Online Therapy & Self-Help Guides
Video/Phone Consultations
Wellness Courses & Training
5. How soon are you looking to start?
Immediately
Within a month
Just exploring for now
6. Personal Bio Details:
Full Name
Age
Gender:
Male
Female
Non-Binary
Other
Occupation:
City & Country:
7. Do you prefer in-person or online sessions?
In-Person (If available in my area)
Online (Video or Phone Call)
No preference
8. What are your biggest challenges right now? (Select up to 3)
Overthinking & Negative Thoughts
Stress & Burnout
Anxiety & Panic Attacks
Low Self-Esteem & Confidence
Relationship Issues
Career Stress & Uncertainty
Emotional Trauma
Lack of Motivation & Direction
9. Have you ever been diagnosed with a mental health condition? (Optional)
Yes (Please specify)
No
Prefer not to say
10. How would you describe your current emotional state?
Very Stressed
Somewhat Stressed
Neutral
Mostly Positive
Very Positive
Do you have any specific goals for therapy or coaching?
12. Preferred Mode of Contact:
Email / Phone Call / WhatsApp / SMS
Email Address:
Phone Number (Optional):
13. Would you like to receive free mental wellness tips and updates from us?
Yes, sign me up for the newsletter
No, not right now
14. How did you hear about us?
Google Search
Social Media (Facebook, Instagram, etc.)
Referred by a friend
Other (Please specify)
15. Any additional comments or questions?
Submit Form
