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SA-MUDRA YUVA HELPLINE 24X7 is conceptualized and implemented by SA-MUDRA FOUNDATION, working for Wellness & Empowerment of Youth & Women with a commitment to promote positive, preventive mental health through psycho-social initiatives. Students, youth and parents are our focus group who can seek Academic consultation, parent Counselling, career Guidance, psychological injuries among youth, addictions, Depression including training in Personality Development and Employment
www.sa-mudra.org +91 9880396331, +919480488430, +91 9743104551
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Reference/ Informant – Counselee / Relative *
Date: *
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Name of the Candidate - Counselee *
Age & DoB
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Educational Qualification(s)
Name of the Institution (Student/Employee/Employer)
Work Experience, If Any
Residential Address (Permanent & Temporary)
Telephone Number
Email Id
Personal Information
Relationship Status (single/married/in relationship)
Hobbies/ Talents
Father’s Name, Qualifications , Occupation
Mother’s Name, Qualifications, Occupation
Parents' Marital Status
Total members in family (Brothers, Sisters, Others)
Family Income (Lakhs per year)
Family History of( Mental Illness / Depression, Suicidal attempts/ Addictions etc.,)
Childhood Behavioral Issues, if any
Why you need counselling? (write your problem briefly)
What do you expect from counselor/ this session
Do these issues listed bother you? *
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