Counseling Application — Alena Alsruhe

Thank you so much for your interest in counseling!

Please fill out the questions below with some information about you and what you’re hoping to gain from this experience, so I can get to know you a little better! I’ll be in touch soon about the next steps! Thank you for taking the time to fill out this form!

Name

First Name

Last Name

Birthday

YYYY

Tell me a little bit about yourself and what your life currently looks like.

What is the number one change you are hoping to make in your life over the next 6 months?

What do you hope to gain from counseling?

Are you currently working with a therapist?

Yes

On a scale from 1-10 how would you rate your mental health?

1 is poor health, 10 is excellent health

On a scale from 1-10 how would you rate your physical health?

1 is poor health, 10 is excellent health

How did you hear about counseling with Alena?

Instagram

YouTube

Email list

Other