Pre-Session Questionnaire

Name*

Phone Number: *

Email*

What is the main reason you are seeking this session? (Select all that apply)*

Stress Management

Anxiety / Overthinking

Relationship Challenges

Work-Life Balance

Low Self-Confidence

Career Guidance

Other

Have you attended therapy or coaching before?*

Yes

No

On a scale of 1-10, how would you rate your current emotional well-being?

1

2

3

4

5

6

7

8

9

10

What is your biggest challenge right now?

What are your top 3 goals for this session?

What do you expect from me as your coach/psychologist?

How committed are you to making changes?

Very Committed

Somewhat Committed

Not Sure Yet

Do you have any preferences or concerns for the session?

Do you agree to maintain confidentiality and respect the session guidelines?

Yes

No

How did you hear about this session?

Instagram

Facebook

Website

Referral

Other