Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which problems best describe your struggles at the moment *

(Tick all that apply)

Overwhelmed

Hard to feel happy

Hard to enjoy usual things

Indecisive

Lack confidence

Irritable

Poor sleep

Fatigue

Appetite change

Negative thinking

Worry

Hopeless

Worthless

Suicidal thoughts

Work issues

Relationships issues with colleagues

Relationship issues with friends

Relationship issues with family

Poor concentration

Reduced productivity

Alcohol and/or drug use

Social withdrawal

Other

How often do you struggle with these issues? *

Most of the time, almost every day

More days than not in a week, most of the day

More days than not in a week, part of the day

1-3 times a week, most of the day

1-3 times a week, part of the day

Which areas of your life do these issues impact? *

Home

Work

Myself

Other