Intake Form Intake Form Newsletter Intake FormDemographic Details EmailPlease choose a date you'd like to book a session on Time slot for the session (if chosen other, please contact me to fix a slot accordingly) 6:30 pm to 7:30 pm 7:30 pm to 8:30 pm 10:00 pm to 11 pm OtherEnter Your TimeYour Phone Number NameAge /Date of Birth Gender Male Female Transgender Non Binary Prefer not to sayOccupation Marital status Single Married Live with partner Seperated/Divorced Widowed OtherIf other put details hereFamily structure Nuclear JointEmergency Contact (Name, Relationship with them, contact number) Note: In this section briefly provide the reasons for seeking counselling All information provided here will be kept confidential. Briefly describe the problems you are facing What has happened recently that made you seek help today? How do you handle stressors/cope with problems you have described? Have you taken counselling before? Yes NoWhat do you hope to be able to do or achieve as a result of treatment? Do you currently have thoughts of harming yourself? Yes NoHave you harmed yourself in the past? Yes NoIf yes, how long ago?Payment Details please provide a screen shot of the payment once completed. please note that the payment is to be done prior to the session scheduled. Charges of per session: Rs. 1000/- Student charges per session: Rs. 450/- Charges for couples therapy: Rs. 2200/- Payment details:upi id: 9619414779@ibl If payment is via bank transfer/NEFT, please contact me on 8655091095/9619414779 for the details. Please attach image of your (present) student ID card. Choose File Please attach screen shot of the paymentChoose File Submit Form Have Any Queries? Wish to get a free consultation or a quick checkup to identify the kind of treatment you need? Just give us a call or submit the form here. +123 456 7890 mail@example.com 123 Fifth Ave, NY 12004, USA.
