Self Care Coaching General Info We put privacy first. Any information provided by you is used to understand your needs and provide a better service. We may use your information for the following: to fulfill your requests in a timely and effective manner, to improve our products or services based on your needs, or to personalize your experience according to your interests. ATMH will not sell, share, or distribute your personal information to third parties. First Last City State/Province Email Phone Birth date Referred by How did you hear about us?—Please choose an option—Social mediaTVPrintSearch engineWord of mouthOther Insurance If you plan to use your insurance, please fill out the fields below. This information will be found on your insurance card. Company ID/Contract Number Group Number Effective Date Demographics We ask the following information because we would like to get to know you better. Your info is confidential and privacy is important. Any information provided by you is used to understand your needs and provide a better service. Gender—Please choose an option—MaleFemaleOther Age—Please choose an option—Under 1313-1819-2526-39Over 40 Race/Ethnicity—Please choose an option—American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteWould rather not to say Preferred Language—Please choose an option—EnglishSpanish Relationship Status—Please choose an option—SingleMarriedDivorcedWidowedSeparatedWould rather not to say Identify as—Please choose an option—StraightLGBTQ+Would rather not to say Self Care Coaching Please select your self care areas of interest. You may select multiple areas of interest. Areas of interest Helping new freshmen on campusHelp dealing with test anxietyHelp building social relationshipsHelp adjusting to social issuesHelp dealing with stress Additional Info Please provide us with any additional information you think we should know. Also, we are always open to feedback and suggestions so feel free to speak your mind. We’re here to answer any of your questions or concerns. WHAT'S NEXT? After submitting this form, you may use the Positivity+ app to join your session and schedule future sessions. Please click the Send button below. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
