Mood Improvement Intake Form
Please fill out this Mood Improvement Intake Form to help us understand your mood improvement goals and context.
Full Name
First Name
Last Name
How would you describe your current mood?
*
Please Select
Very Positive
Positive
Neutral
Negative
Very Negative
What is your primary goal for improving your mood?
*
How long have you been experiencing your current mood?
Please Select
Less than a week
1-4 weeks
1-6 months
More than 6 months
What factors do you believe are affecting your mood?
Work or studies
Relationships
Health or wellness
Sleep
Diet or nutrition
Other
What strategies have you already tried to improve your mood?
Exercise
Talking with friends or family
Mindfulness or meditation
Hobbies or creative activities
Professional support
Other
How often do you experience changes in your mood?
Please Select
Rarely
Sometimes
Frequently
Almost always
What support systems do you have in place?
Friends
Family
Co-workers or classmates
Community groups
None
Other
Is there anything else you'd like to share about your mood or your goals?
Submit
Should be Empty: