Rotary Club of Jammu Elite
Offers online Covid-19 crisis counselling and mental health intervention service

We are glad to know that you plan to seek counseling during the covid-19 outbreak. In order to utilize the counseling service, please fill the following form. You will be given time based on the availability of the counselor in the time you choose. These are a few questions to get to know you better before the initial counseling sessions, so that we can help you better. However, for us to help you better, you must answer these questions as frankly and truly as possible. Please note that all this information answered in this form will be kept confidential.
Email address *
Name *
Age *
Gender *
Address *
Mobile No. *
Present Living With *
Marital Status *
Most suitable counseling time (Monday-Saturday) *
Please describe your main concern for which you are seeking counseling for *
What are your expectations from the counseling sessions *
Required
Occupation information *
Please describe your issue for which you are seeking counseling. State your main concern. *
Medical/ Physical Health *
Undertaking: I am aware the counseling is online through the verbal-audio medium. I hereby submit that I would not involve in any form of recording of the session or its distribution in any form. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy