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Let's start with where you are at.

The below questionnaire will help us understand your starting point so when we get on a call we have some basics covered, leading to much more focused conversation.  If you prefer to do things another way just email us at name@mindyourspace.com. 

Let's start with where you are at.

Please take a moment to fill in this quick questionnaire.

Example: “Feeling overwhelmed,” “Improving focus,” “Looking for non-talk approaches,” “Anxiety and sleep issues,” “Curious about neurofeedback.

Select all that feel interesting or relevant to you:
Safety & Considerations: Have you ever been diagnosed with or experienced any of the following? (This helps us ensure safe and ethical recommendations)
Select any that currently apply to you:
Are you currently in therapy or working with a healthcare provider?
No
Yes
Do you take any medications or supplements that affect mood, sleep, or focus?
No
Yes
If yes (select all that apply)
How did you hear about mindyourspace?
Consent & Acknowledgment:
I accept

By submitting this form, I acknowledge and understand the following:

Purpose: mindyourspace offers integrative wellness and educational services that support nervous-system regulation, emotional awareness, and self-growth. These services are not a substitution for psychotherapy, counseling, or medical treatment care.
I accept

Voluntary Participation: My participation is voluntary, and I may pause or discontinue at any time.

Safety and Scope: If I am in crisis or experiencing an emergency, I will contact emergency services (911) or a crisis hotline (988) rather than this form.
I accept

Confidentiality: Information shared through this form is private and used solely for scheduling, assessment, and care coordination purposes within mindyourspace.

Data Use: My contact information may be used to follow up about services, resources, or recommendations related to my stated interests. It will not be sold or shared externally.
I accept all the above

Consent: By selecting "I accept all the above" option, Date, and Time below, I give consent to participate in services and acknowledge that I have read and understood the information above.

Thank you for taking the time to fill this out.

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