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Your name

Your email

Your WhatsApp Number

Your Age

How would you describe your current level of stress?
—Please choose an option—Not stressed at allA little stressedModerately stressedQuite stressedExtremely stressed

How often do you feel overwhelmed in your daily life?
—Please choose an option—RarelyOccasionallyFrequentlyVery oftenAlmost always

Do you experience mood swings?
—Please choose an option—YesNo

If you do experience mood swings, how long do they typically last?
—Please choose an option—Just a few daysAround a weekAbout two weeksMore than two weeks

Over the past week, how would you describe your appetite? (e.g., not feeling hungry or eating more than usual)
—Please choose an option—Not at allOccasionallyQuite oftenConsistently

How would you rate your sleep quality over the past week?
—Please choose an option—PoorFairGoodVery goodExcellent

How satisfied are you with your personal relationships?
—Please choose an option—Very dissatisfiedSomewhat dissatisfiedNeutralSomewhat satisfiedVery satisfied

Do you feel adequately supported by your friends and family?
—Please choose an option—YesNo

Have you experienced any traumatic events recently?
—Please choose an option—YesNo

Have you faced any significant losses recently (e.g., death of a loved one, divorce)?
—Please choose an option—YesNo

In which areas of your life are you seeking growth or improvement?
—Please choose an option—Emotional & Mental HealthRelationships & Social IssuesCareer & Life TransitionsHealth & Well-BeingPersonal GrowthSpecial Circumstances

Is there anything else you would like to share about your emotional well-being?