Calming Resources Intake Form
Please complete this form to help us understand your preferences and needs for calming resources. Your responses will assist us in providing the most suitable support.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What brings you to seek calming resources?
*
How would you rate your current level of stress or anxiety?
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Which calming methods have you tried before?
Meditation
Breathing Exercises
Yoga
Listening to Music
Nature Walks
Other
Which type of calming resources are you interested in?
*
Guided Meditation
Aromatherapy
Soothing Music Playlists
Mindfulness Exercises
Art or Coloring Activities
Other
Do you have any allergies, sensitivities, or accessibility needs?
Preferred way to receive resources
In-person session
Online/digital materials
Printed handouts
No preference
What is your preferred time for receiving calming resources or sessions?
Please Select
Morning (8am - 12pm)
Afternoon (12pm - 5pm)
Evening (5pm - 9pm)
No preference
May we contact you for follow-up or additional support?
Yes, via email
Yes, via phone
No, thank you
Is there anything else you would like us to know or any specific concerns you have?
Submit
Should be Empty: