Wellness Questionnaire - Tanielle L.A. Brown

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Referral Wellness Questionnaire

Thank you for your interest in our referral wellness program. We understand that everyone’s wellness journey is unique, and we want to ensure we provide you with the most suitable options for mental health therapy, support groups, life coaching, frequency therapy, virtual therapy, and assistance with coordinating mental health retreats. Kindly take a few moments to complete the following questionnaire. Your responses will help us gain a deeper understanding of your needs and preferences.

Personal Information

Name*

Age*

Gender*

Email Address*

Phone Number*

Which of the following wellness services are you currently seeking? (Please check all that apply)

Mental health therapy/counseling: If you're experiencing emotional or psychological difficulties and would benefit from professional guidance and support. Support groups: If you're interested in connecting with others who are facing similar challenges and would like to engage in group discussions and activities to promote mutual support. Life coaching: If you're seeking guidance and support in achieving personal or professional goals, improving specific areas of your life, or enhancing overall life satisfaction. Frequency therapy (e.g., neurofeedback, biofeedback): If you're open to alternative therapies that focus on regulating brainwave activity or physiological responses to promote relaxation, focus, and mental well-being. Virtual/online therapy: If you prefer receiving therapy or counseling services through online platforms, allowing for convenience and accessibility from the comfort of your own home. Assistance with coordinating mental health retreats: If you're interested in organizing a mental health retreat for yourself, your business, or a group of friends/family members and would like assistance with the planning and logistics. Mommy retreats: If you're a mother seeking a retreat specifically designed to address the unique challenges and needs of motherhood, such as self-care, stress management, and support from other mothers. Spa retreats: If you're looking for a rejuvenating and relaxing retreat experience that incorporates spa treatments, wellness activities, and opportunities for self-care. Other (please specify):

Others

What specific challenges or issues are you currently facing that you would like assistance with? Please provide a brief description of your current situation, areas of concern, or goals you would like to address through the wellness services you're seeking.

Have you sought any of the mentioned wellness services in the past? If yes, please briefly describe your experience and outcomes. This will help us understand your previous experiences and tailor our recommendations accordingly.

Are you interested in individual or group therapy/support/coaching sessions? Individual sessions provide one-on-one attention, while group sessions offer the opportunity to connect with others experiencing similar challenges and provide mutual support.

How frequently would you prefer to attend therapy/support sessions? Please indicate your preferred frequency, such as weekly, bi-weekly, or monthly sessions.

Are you interested in in-person sessions, virtual/online sessions, or both? Let us know your preferences for the format of the wellness services you're seeking.

If you are seeking assistance with coordinating mental health retreats, please provide additional details about your preferences. This includes the purpose of the retreat, preferred location, duration, and approximate number of participants (if applicable). The more information you provide, the better we can assist you in organizing a tailored mental health retreat experience.

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Referral Wellness Questionnaire

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Referral Wellness Questionnaire

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Scan my qr code