Mental Health Recommendation Questionnaire Form
Please answer a few general questions to help us recommend the most suitable next-step mental health support option. This is not a diagnostic or medical form.
Your Name (optional)
First Name
Last Name
Email Address (optional, for follow-up)
example@example.com
What is your age group?
*
Please Select
Under 18
18–24
25–39
40–59
60 or older
Which of the following best describes your current support situation?
*
I have never sought support before
I am currently receiving support
I have received support in the past
Prefer not to say
What is your primary area of concern?
*
Please Select
Stress or overwhelm
Low mood or motivation
Anxiety or worry
Relationship or family issues
Work or academic challenges
Other (please specify)
How urgent do you feel your need for support is?
*
Not urgent – just exploring options
Somewhat urgent – would like support soon
Very urgent – need support as soon as possible
Which support method are you most comfortable with?
*
One-on-one conversation
Group support
Online resources or self-guided tools
Not sure yet
What days/times are you generally available for support (optional)?
Is there anything else you’d like us to know about your preferences or situation? (optional)
Get Recommendation
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