You are experiencing difficulties concentrating or experiencing forgetfulness. *

YES

NO

You have lost satisfaction in your achievements, both personally and/or professionally. *

YES

NO

You are experiencing difficulties sleeping at night. *

YES

NO

You are experiencing increase irritability with colleagues, clients or customers. *

YES

NO

You are feeling callousness or cynicism or negativity relate to your day to day duties. *

Yes

No

You have experienced frequent headaches or muscle pains. *

Yes

No

You are using food, drugs and/or alcohol to feel better or avoid feeling. *

Yes

No

You feel like no one understands what you are going through. *

Yes

No

You feel like you are achieving less than you should. *

Yes

No

You are experiencing unexplained wave of sadness. *

Yes

No

Name *

First Name

Last Name

DOB

MM

DD

YYYY

Send me Modern Mental Wellness Tips for Millennial Women. *

YES Please

NO Thank you