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Intake.

Welcome to Roots Enroute.
We are here to support you in taking this important step toward seeking mental healthcare support, resources and care.

Note: Your responses received via this form will be handled solely by our founder Krittika - who manages both therapy and administrative responsibilities. The information is securely stored in password-protected folders, following professional mental healthcare standards.

You can reach us at [email protected] regarding any queries.

Name

(how you would like us to call you)

Pronouns

(How you like us to refer to you)

Age group

Contact details

(Preferably WhatsApp)

Current place of residence

Language Preferences

(You may select one or more)

Language Preferences

English

Hindi

Marathi

Current role

I'm a student

I'm a professional

Other

Have you been in therapy before?

Yes, I have previous experiences of being in therapy

No, this is my first time reaching out

I'm seeking support for..

Complete this sentence in as brief or elaborate way you wish to.

I came across Roots Enroute via

Social media like Instagram, LinkedIn, Facebook etc.

Word of mouth

Other professionals like medical practitioners, mental health professionals etc.

Workshop offerings attended

Other

Any message/questions that you would like to leave us.

- Disclaimer -

I agree

That I have read and understood all the above information provided to me

Untitled checkboxes field

That the information I've filled is accurate to the best of my knowledge

To be contacted by Roots Enroute

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