Date
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Last Name
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Please indicate which stress management services you are interested in (check all that apply):
Introduction to Stress Management Workshop (General Overview):
Covers basic stress concepts, identification of stressors, and introductory relaxation techniques.
Mindfulness and Meditation Workshop:
Focuses on cultivating present-moment awareness and utilizing meditation for stress reduction.
Cognitive Behavioral Techniques for Stress Workshop:
Teaches how to identify and modify negative thought patterns contributing to stress.
Time Management and Organization Workshop:
Provides strategies for prioritizing tasks, managing time effectively, and reducing overwhelm.
Emotional Regulation and Resilience Workshop:
Explores techniques for managing emotional responses and building resilience to stressors.
Stress and Physical Health Workshop:
Explores the connection between stress and physical health, and how to improve both.
Customized One-on-One Stress Management Coaching:
Tailored sessions to address individual needs and goals.
Corporate/Group Stress Management Workshop:
For teams or organizations, focused on workplace stress.
What are your primary reasons for seeking stress management support?
On a scale of 1 to 10 (1 being minimal stress, 10 being extreme stress), how would you rate your current stress level?
What are some of the common stressors in your life? (e.g., work, relationships, finances, health)
How long have you been experiencing elevated stress levels?
Less than 1 month
1-3 months
3-6 months
More than 6 months
What physical symptoms do you experience when stressed? (e.g., headaches, muscle tension, sleep disturbances, digestive issues)
What emotional symptoms do you experience when stressed? (e.g., anxiety, irritability, sadness, difficulty concentrating)
Have you used any stress management techniques in the past? If so, which ones?
Are you currently receiving any other form of therapy or counseling? If so, please explain.
Do you have any medical conditions or physical limitations that we should be aware of?
What are your goals for participating in these stress management workshops/services?
Are you taking any medications that could affect your participation in relaxation techniques?
Do you have any questions or concerns about the workshops/services offered?
I understand that all information provided in this form will be kept confidential, except as required by law.
I consent to participate in the stress management workshops/services and agree to follow the guidelines provided by the facilitator.
Client Signature
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