Client Intake Form
Hello! Thank you for reaching out! We are a team of psychologists working in the field of mental health. All our psychologists are qualified, experienced, trauma-informed and queer affirmative.
Once you fill the form, we will reach out to you according to the availability. Thank you for your patience. All the details you share will strictly remain confidential.

Note- Since we are not a crisis management organization, in case of any emergencies, adequate references will be provided to you. In addition to this, we recommend visiting nearby hospitals having a psychology/ psychiatry ward if you require emergency sessions.

Contact Details-
Whatsapp Number-  +91 7249091360

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Full Name(completely confidential) *
Age *
Contact number (Whatsapp number only) *
Email id *
Profession *
Few details about the concerns you are facing- *
Did you have any suicidal ideation in past 2 months?  *
Previous clinical history/Psychiatric medicine history, if any(Kindly mention if you have been diagnosed with any psychiatric disorder) *
Country that you are based in- *
Reference from *
Preferred Session Mode *
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