Full Name

Preferred Name

Date of Birth

Gender Identity Gender IdentityFemaleMaleNon-binaryPrefer not to say

Preferred Pronouns

Your Email Address

Your Mobile Number

Support Needs- What mental health challenges are you currently facing? (Check all that apply) Support Needs- What mental health challenges are you currently facing? (Check all that apply) Anxiety Depression Stress or Burnout Trauma Family Relationships Grief Relationships Academic or Career related challenges Loneliness & Isolation Self Esteem Self Harm and/or suicidal ideation Other

If Other, please elaborate:

Have you received professional counseling before? Have you received professional counseling before? yesno

If Yes, would you like to continue with a similar approach or try a different one?

Preferred Counseling Approach (check all that apply) Preferred Counseling Approach (check all that apply) Talk therapy Cognitive behavioural therapy Mindfulness and relaxation approaches Mentorship approach Trauma informed support Other

If Other, please elaborate:

Preferred Session Format Preferred Session FormatPhone callVideo call - Zoom or Google MeetingsBoth

How did you hear about Athenie’s Angels? How did you hear about Athenie’s Angels?Social MediaWebsiteFriend/Peer/FamilyOther

Is there anything else you’d like us to know?

Consent & Agreement (Check the boxes below if agreeing to consent.) Consent & Agreement (Check the boxes below if agreeing to consent.) I consent to receiving counseling support from Athenie’s Angels. I understand that Athenie’s Angels is a non-profit organisation and does not provide emergency crisis support or medical treatment. By submitting this form, I acknowledge that my information will be kept confidential and used solely for the purpose of securing counselling support by our youth counsellor.