Therapy Intake Form
Congratulations on taking the first step towards improving your mental health!

How it works:

1) Fill out this Intake Form
2) I will reach out to you over email to fix an appointment
3) Initial assessment session
4) Weekly sessions, if we are a good fit.

All sessions will be conducted over a zoom video call.
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Full Name *
Age *
Pronouns *
Primary Language *
Occupation *
City/State *
Phone Number/Whatsapp *
Email ID *
How did you hear about me?  *
What is your reason for seeking therapy? *
Have you sought therapy before? *
If yes, when?
What are your expectations from therapy? *
Have you been/are you currently on any psychiatric medication? *
If yes, please list down the prescribed medication + when it was prescribed.
Have you ever been hospitalised for any psychiatric reason? *
If yes, when + for what reason?
Have you ever had thoughts about suicide? *
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