holisticmindspsychiatry.com

SECTION 1 — WHO YOU ARE

First Name

Last Name

Email Address *

Confirm Email Address *

Age *18–2425–3435–4445–5455+

Profession

SECTION 2 — YOUR CURRENT EXPERIENCE

Which best describes your primary struggle?(multiple choice – select up to 2)Chronic worry / overthinkingHigh-functioning anxietyPerformance or pressure-related anxietyNervous system dysregulation (restlessness, tension, fatigue)Burnout or emotional overwhelmOther

On a scale of 1–10, how much is anxiety currently impacting your life or performance?(linear scale 1–10)

At this time, my services are best suited for individuals experiencing moderate to high impact anxiety.

SECTION 3 — READINESS FOR THIS WORK

Have you previously tried therapy, medication, or self-help tools for anxiety?YESNO

Are you open to a natural, evidence-based approach focused on nervous system regulation and personal responsibility (not quick fixes)?YESNOUNSURE

My approach may not be the right fit at this time.

SECTION 4 — SAFETY & APPROPRIATENESS

Which of the following are you currently experiencing?(Select all that apply)Active suicidal thoughtsSevere untreated depressionActive substance dependencePsychosis or mania

Thank you for your honesty. At this time, higher-level or specialized clinical care would be more appropriate.

SECTION 5 — COMMITMENT & INVESTMENT

This is a premium, transformational service that requires time, consistency, and financial investment. Are you prepared to invest in your mental wellness at this level?YESNOPOSSIBLY

This program is not the right fit at this time.

SECTION 6 — VISION & ALIGNMENT

If anxiety were no longer in control, what would change most in your life?

Why do you believe this work—and working with me specifically—feels aligned for you right now?