Intake form

Name *

Email address *

What is your age?

What is your gender?

What is your current occupation?

Do you have any previous experience with mental health services?

What specific mental health challenges are you facing?

Please select at least one option.

Anxiety

Depression

Substance Use Disorder

Stress Management

Trauma

What goals do you hope to achieve through our services?

How did you hear about mindful renewal?

What is your preferred method of communication?

Would you like to schedule an in-person visit at our port harcourt location?

Which service or services are you interested in?

Please select at least one option.

Individual counseling

Group therapy

Workshops and seminars

Initial consultation

Follow-up consultation

Additional questions or comments

Mindful Renewal