Intake form

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Intake form

Hello there,

My name is Sagar Takker. I am an aspiring counselling psychologist, pursuing M.Sc. in Psychology from Banaras Hindu University. As an effort in the direction of becoming a mental health professional, I am offering pro-bono sessions under the supervision of my faculty. Please fill the form below to get in touch.

All information will be kept strictly confidential.
It is my honour and pleasure to assist you.

After receiving a response to this form, I'll schedule a 15 minute consultation call to help you understand how therapy works, my approach as a therapist and to answer any questions that you might have. A refundable deposit of Rs. 350 is sought as a token of commitment towards the process. The amount is refunded upon termination of therapy.

DISCLAIMER: PLEASE DO NOT FILL THIS FORM IF YOU ARE IN A LIFE-THREATENING SITUATION SUCH AS SUICIDE OR SELF-HARM. VISIT http://www.aasra.info/helpline.html FOR A LIST OF SUICIDE HELPLINES INSTEAD.

Name *

Pronouns *

Date of birth *

YYYY

Whatsapp Number
*

Email *

Profession *

What would you like to work on in therapy?  For example, problems you would like to solve, issues from which you’d like to heal, goals you desire or outcomes you want. *

What are the 3 most important changes you would like to make in your life? *

On a scale of 1 to 10 how committed are you to get the results and changes you desire? *

Not at all

Really committed

Any other information (for example information from medical professionals and healthcare specialists)

Send me a copy of my responses.

Submit

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