CBT Psychoeducation Intake Form
Please complete this form to help us tailor your CBT psychoeducation experience. All information is kept general and is used to support your learning journey.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age Range
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
How did you learn about CBT psychoeducation?
Referral from a professional
Internet search
Social media
Friend or family
Other
What are your main goals for participating in CBT psychoeducation?
*
Have you previously participated in any psychoeducational or self-help programs?
Yes
No
Which CBT topics are you most interested in learning about?
*
Understanding thoughts and beliefs
Managing emotions
Behavioral strategies
Mindfulness techniques
Other
What is your preferred learning style?
Visual (videos, diagrams)
Auditory (audio, podcasts)
Reading/Writing (articles, worksheets)
Interactive/Hands-on
Other
Is there anything else you would like us to know to help personalize your CBT psychoeducation experience?
Submit
Should be Empty: