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QUESTIONNAIRE - OVERCOME ANXIETY

PLEASE READ: Responses to all questions are optional; the information you provide helps us tailor recommendations to your specific needs. All of the information is confidential and will not be reproduced or transferred.

First Name

Last Name

Email Address

Which program are you interested in?

Introduction Workshop ($35)

Eight-week Follow-up Program ($175)

Both ($200)

Which day & time do you prefer?

Tuesday/Wednesday Mornings 9:30am -12:00 pm CST

Tuesday Evenings 5:30pm-8pm CST

Sunday Afternoons 4:00pm-6:30pm

How long have you had symptoms of anxiety?

Which of the following symptoms do you experience?

shallow breathing

tightness in your chest

shakiness

inability to fall or stay asleep

mental fogginess

chronic irritability

emotional outbursts

butterflies in your belly

obsessive fearful thinking

avoidance of previously enjoyable activities

Please list all the symptoms you would like to address/remedy in this program.

Do you currently suffer from panic attacks? If yes, how many and how often?

Do you exercise?

Yes

No

If yes, please briefly describe your routine and how often.

Is there anything else you care to share or receive additional information about?

Your Signature

Today's Date

Thanks for submitting!

Get in Touch

Let's connect... I would love to hear from you!

PO Box 45

Sugar Land, TX. 77487

susangrace@mindfulgraces.com

Thanks for submitting! Talk to you soon!

© 2020 by Mindful Graces.

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