Counseling Practice Support Consultation Request Form Template

The form itself

Blocks included

These are the exact starting questions and content blocks that will appear in your ResponseMint workspace.

1. 01
   Short answer · Grouped page

   What is your name?

   Required
2. 02
   Email · Grouped page

   What is your email address?

   Required
3. 03
   Dropdown

   Which service are you considering?

   • Individual counseling
   • Couples counseling
   • Teen support
   • Remote counseling
   Required
4. 04
   Dropdown · Grouped page

   What type of support are you seeking?

   • Individual
   • Couples
   • Family
   • Not sure
   Required
5. 05
   Dropdown · Grouped page

   Which format works best?

   • In person
   • Video
   • Phone
   • Flexible
   Required
6. 06
   Multiple choice

   When would you like to begin?

   • Immediately
   • Within a month
   • Within three months
   • Just researching
   Required
7. 07
   Long answer

   Tell us what you want to achieve

   Find a suitable counselor, Clarify support options, Arrange a first conversation, Feel heard and supported

   Required
8. 08
   Multiple choice

   How should we follow up?

   • Email
   • Phone
   • Video call
   • No preference
   Required