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Lead Capture Form

What has been feeling most overwhelming lately?

Which of the following have you been experiencing recently? (Select all that apply)

Ongoing worry or racing thoughts

Emotional exhaustion or burnout

Panic episodes or sudden surges of fear

Low motivation or difficulty getting started

Persistent fatigue or mental fog

Sleep disruption

Feeling emotionally numb or disconnected

Overwhelm after a major life change (including becoming a parent)

Something else not listed

How are these experiences affecting your day-to-day functioning? (Select all that apply)

Difficulty concentrating or staying organized

Lower tolerance for stress or pressure

Trouble completing tasks

Withdrawing from others or activities

Difficulty keeping up with responsibilities

Feeling close to a breaking point

Are these experiences beginning to affect your ability to work or keep up with responsibilities? (Select one)

Yes, significantly

Somewhat, but I am still managing

Not yet, but I am concerned

I am not sure

What kind of support are you hoping for right now? (Select all that apply)

Clarity about whether taking time away might help

Support managing emotional overload

Help thinking through next steps

Short-term guidance during a difficult period

I am not sure yet

Are you currently employed? (Select one)

Yes

Recently stopped working

Currently on leave

Prefer not to say

Full Name

Phone Number

Confirm Phone Number

Email Address

Confirm Email Address

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