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Diabetes Distress & Burnout
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Intake form
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Name
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Email address
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What is your age group?
Select
13-17
18-24
25-34
35-44
45-54
55-64
65 and above
What type of diabetes do you have?
Please select at least one option.
Type 1
Type 2
Gestational Diabetes
Prediabetes
How long have you been managing diabetes?
Select
Less than 1 year
1-5 years
6-10 years
More than 10 years
What challenges do you face in managing your diabetes?
Please select at least one option.
Diet and Nutrition
Physical Activity
Medication Management
Emotional Well-being
Monitoring Blood Sugar
Social Support
Have you ever experienced diabetes burnout?
Select
Yes
No
What coping strategies do you currently use?
Please select at least one option.
Exercise
Meditation
Support Groups
Professional Counseling
Self-education
Journaling
What resources do you find most helpful?
Please select at least one option.
Diabetes Educators
Support Groups
Online Communities
Books and Publications
Mobile Apps
Health Professionals
What are your goals for diabetes management?
Which service or services are you interested in?
Please select at least one option.
1:1 Coaching
10 week Live Group coaching Program
Emotional support groups
Additional questions or comments
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