Coping Strategies Intake Form
Help us understand your coping methods, challenges, and preferences to better support your well-being.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
How would you rate your overall stress level in the past month?
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Which of the following coping strategies do you use regularly? (Select all that apply)
*
Talking to friends or family
Physical exercise
Meditation or mindfulness
Creative activities (art, music, writing)
Distraction (TV, games, internet)
Seeking professional help
Other
How effective do you find these coping strategies?
*
Rows
Not Effective
Somewhat Effective
Very Effective
Talking to friends or family
1
2
3
Physical exercise
4
5
6
Meditation or mindfulness
7
8
9
Creative activities
10
11
12
Distraction
13
14
15
Seeking professional help
16
17
18
Other
19
20
21
How frequently do you use each coping strategy?
*
Rows
Never
Rarely
Sometimes
Often
Always
Talking to friends or family
22
23
24
25
26
Physical exercise
27
28
29
30
31
Meditation or mindfulness
32
33
34
35
36
Creative activities
37
38
39
40
41
Distraction
42
43
44
45
46
Seeking professional help
47
48
49
50
51
Other
52
53
54
55
56
When do you most often use your coping strategies?
*
During stressful events
When feeling anxious
When feeling sad or depressed
To prevent negative emotions
Other
What challenges do you face when trying to cope with stress?
Are there coping strategies you would like to try or learn more about?
Would you be interested in receiving resources or support related to coping strategies?
*
Yes
No
Submit
Should be Empty: