Intake form

Name *

Email address *

What is your age group?

What is your gender?

Which mental health topics are you interested in?

Please select at least one option.

Depression

Anxiety

Stress Management

Bipolar Disorder

Eating Disorders

PTSD

Substance Abuse

How did you hear about us?

Please select at least one option.

Social Media

Friend or Family

Online Search

Do you currently seek help for mental health issues?

What type of resources are you looking for?

Please select at least one option.

Information on disorders

Support groups

Success stories

Coping strategies

Professional help

Interactive games

Additional questions or comments

MentalHealthStigma - Breaking the Ice