THE MENTAL GYM

WELCOME TO

Premium Holistic Lifestyle Therapy
by Gabriela Bolivar Villalobos, PhD

The Mental Gym

Premium Holistic Lifestyle Therapy - Client Screening & Interest Form

About Our Program: We offer an integrative approach to mental wellness combining individual psychotherapy, nutrition recommendations, and exercise programming. This comprehensive package is designed for individuals seeking more than just talk therapy who also want to optimize their mental health through a holistic approach.

Personal Information

Full Name

Phone

Age

Do you currently live in California?

Yes

How do you prefer to pay for services?

Private Pay / Cash (Self-Pay)

Insurance Coverage

Open to Either Option

Mental Health Background

What are your primary goals for therapy?

Have you participated in therapy before?

Yes

How would you describe your current mental health?

Stable - Looking to optimize and maintain mental wellness

Experiencing mild stress, anxiety, or mood concerns

Experiencing moderate challenges that affect daily life

Experiencing severe depression, anxiety, or other significant symptoms

Are you currently experiencing any of the following? (Check all that apply)

None of the below

Suicidal thoughts or ideation

Self-harm behaviors

Severe depression impacting ability to function

Active substance abuse requiring treatment

Important: Our program is designed for individuals with stable mental health seeking optimization and growth. If you are experiencing severe symptoms, active crisis, or high-risk concerns, we will provide appropriate referrals to specialized care providers who can better meet your needs.

Crisis Support: If you are in crisis or experiencing suicidal thoughts, please call the Suicide & Crisis Lifeline at 988 or text 988 for immediate support. Call 911 if you are in immediate danger of hurting yours

Are you currently taking any psychiatric medications?

Yes, and my medication is stable

Yes, currently adjusting medications

What interests you most about our comprehensive program? (Check all that apply)

Individual psychotherapy

Nutrition guidance for mental health

Exercise programming

The integrated, holistic approach

Current exercise/physical activity level:

Little to no regular activity

Light activity (1-2 times per week)

Moderate activity (3-4 times per week)

Very active (5+ times per week)

How motivated are you to make lifestyle changes to support mental health?

Very motivated - ready to commit

Somewhat motivated - open to exploring

Unsure - want to learn more

How long are you willing to commit to making lifestyle changes in your life?

30 days or less

1-3 months

4-6 months

6 months +

Additional Information

Is there anything else you'd like us to know?

How did you hear about our practice?