Therapy Intake Form
Hello!

I am Akshi, a Mental Health Practitioner based in Mumbai.

This form is a confidential brief intake before we can set up a consultation call for you. This call will aim at understanding what brings you to therapy, address and questions you have and discuss the process further.
Please fill this out with as much accuracy as you can. Once filled, based on availability of slots, I will get in touch with you to schedule consultation call. I will also provide you with a form of consent before the first appointment.

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Email *
Name and pronouns *
Contact Number *
Age *
Referred by/How did you find me? *
Location *
Education and Profession *
What brings you to therapy?
 *
Can you afford the full session fee of INR 2200? *
Preferred Time Slots to schedule a 20 minute call *
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