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Counselling Intake Form
For Urgent cases, please mention {URGENT} along with your issue under the "Present complaint/ problem" region
Please help us know you better by filling in the form below and we will get back to you shortly, insha Allah. Jazakallah Khayr.
Name
Email address *
Gender
Age
Marital Status
Nationality *
Present complaint/problem *
Order of Birth
Number of Siblings (if any)
Any history of complications at birth?
Any history of complications during childhood?
Any history of psychiatric illness?
Any history of psychiatric illness in parents?
Any history of academic complaints in School/College?
How is your relationship with parents?
How is your relationship with friends?
How is your relationship with siblings (if any)?
How is your relationship with spouse (if any)?
How did you hear about us?
Disclaimer:
We are not licensed professionals and hence do not handle clinical cases.

At the moment, our services are limited to guidance counseling via email only. If you require assistance in Fiqh matters, please contact a scholar. We do not handle Fiqh matters of any sorts.

If you are suicidal, we recommend you immediately contact a suicide prevention helpline in your locality.

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