INTAKE FORM
Hello!
Thank you for reaching out and taking the first step toward your mental well being.
I am Sejal Agrawal, a clinical psychologist with 6 years of experience.
Seeking support takes courage, and filling out this form is a strong first step toward prioritising your mental health.

My Instagram- https://www.instagram.com/therapyroom.in?igsh=MTVlcXRmMW14OWcx&utm_source=qr

Mode: Online (Google Meet) or Offline
Duration: 45-55 minutes session
Before We Begin please fill this short form (2–3 minutes),it will help me get a better sense of your background and needs before our first session. All your responses are confidential and treated with respect and care.
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Name *
Age *
Gender *
Pronoun *
Date of Birth  *
MM
/
DD
/
YYYY
Phone number (whatsapp) *
Email id *
Your preferred mode of contact  *
Current Residence *
Education Qualification *
Occupation *
Relationship Status *
What issues are you facing? *
Have you had any prior experience with therapy or counselling? *
Have you ever been diagnosed with mental health conditions? *
Are you currently on any psychiatric medication *
Please provide an emergency contact of someone you trust and your relationship with them. (Eg. mother) *
How did you get to know about my practice? (Instagram, LinkedIn, Referral, Friend) Please mention their name *
When would you like to schedule a session? *
Our sessions follow a sliding scale fee structure. Please select the option that applies to you: 

₹1200 per session (Indian Clients)

 ₹2200 per session (Non-Resident Indian Clients)

Kindly note that session charges are increased yearly in January to reflect factors such as continued professional development, increased cost of living, and inflation. 
We shall discuss these changes in advance. Next fee revision shall be in January 2027.
Are you comfortable paying the said amount?
 *
Any other information you want me to have?(family history, medication etc.)
"Kindly read this linked Consent form  carefully and indicate your agreement by accepting the terms and conditions. If you have any questions or concerns, feel free to contact us via email."

By Ticking below, you confirm that you have read and understood this document and consent to begin therapy with Sejal Agrawal, Therapyroom.

This consent remains valid for the duration of the therapeutic relationship unless major changes occur in the nature of services provided. You may withdraw consent at any point in writing.

I have read all the Terms & Conditions mentioned in the consent form and I agree to them.
 *
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