Sora Light Therapy

Home
About
Services
Intake Form
Book a session

Home
About
Services
Intake Form
Book a session

Intake Form

Newsletter

Intake Form

Demographic Details

Please 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

Other

Enter Your Time

Your Phone Number

Name

Age /Date of Birth

Gender

Male

Female

Transgender

Non Binary

Prefer not to say

Occupation

Marital status

Single

Married

Live with partner

Seperated/Divorced

Widowed

Other

If other put details here

Family structure

Nuclear

Joint

Emergency 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

What do you hope to be able to do or achieve as a result of treatment?

Do you currently have thoughts of harming yourself?

Yes

Have you harmed yourself in the past?

Yes

If 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 payment

Choose File

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.

Intake Form

Intake Form

Intake Form

Demographic Details

Note: In this section briefly provide the reasons for seeking counselling All information provided here will be kept confidential.

Payment Details

Have Any Queries?

+123 456 7890

mail@example.com

123 Fifth Ave, NY 12004, USA.