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Burnout Intake Form

We believe that self-reflection is essential in addressing and overcoming burnout. This Burnout Intake Form is designed to help us gather information about your current situation and develop a personalized plan that addresses your unique needs. We appreciate your willingness to be honest and vulnerable throughout this process, and we look forward to working with you towards a healthier, happier you.

Intake Form

Please take a moment to fill out the form.

Current Situation

Burnout Symptoms



Goals and Aspirations

Self-Care and Coping Strategies:

Additional Information:

Thanks for submitting!

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