Intake form

Help us serve you better

Name *

Email address *

What type of support are you seeking?

Please select at least one option.

Emotional support

Mental health support

General listening

Crisis intervention

How did you hear about us?

What is your preferred method of communication?

What time zone are you in?

What is your age group?

Do you have any specific topics you would like to discuss?

What is your preferred language for communication?

Have you used a listening service before?

What are your availability preferences for sessions?

Additional questions or comments

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We Are Ready to Listen