Counseling Program Enrollment

Welcome to this program! Please answer the following questions to help us best support you. Taking charge of your mental health, wellbeing and healing is empowering. It is our honor to be entrusted to serve you. Thank you so much!

Your information is transferred through a secure network and kept confidential. Only the Executive Director and the Counselor who will be working with you will review your information. Demographic data will be used in our nonprofit reporting, however your name and personal contact information will remain anonymous from the data.

Name

First Name

Last Name

How has stress, anxiety or depression affected you in your daily life?

What are your coping skills and how effective are they in living with stress, anxiety or depression?

State specifically and practically your goals in participating in this program?

Do you have experience with mindfulness or meditation? (experience is not required)

Have you participated in counseling before? If so, when?

Testimonial—

“I am now more aware of decisions that will genuinely help me achieve happiness in the short-term and long-term. Being more mindful has helped me be more compassionate towards myself, which is very important as the world we live in sends us so so many negative messages about ourselves. I have learned so much from this program, and I am so thankful!!”

— Counseling Program Participant

Counseling Program Enrollment

We are going back to our roots while we grow into the new—we are rooted to rise.