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Therapy Booking and Intake Form

Hello there!
I am so proud of you for reaching out
Taking the first step toward therapy can feel like a big decision, and I appreciate you taking that first step. I will do the best I can to support you in this journey.
A little about me:
I am Bhargavi Rompally, founder of UnwindWithB. I see therapy as a process of discovering, owning, and sharing your story—whether it’s about life, relationships, or personal struggles.
I use a mix of REBT, CBT, and Gottman strategies, but there’s no one-size-fits-all here. Every session is personalized to what you need. I provide sessions for individuals (of age group 15 to 45) to address stress, anxiety, anger, relationships, and career confusion.
My standard session fee is ₹1500. I also offer sliding scale options, starting at ₹500, 3 sessions every month, depending on availability.
About the form:
Whether you're looking for clarity, support, or just a space to process things, this form is the starting point for us to get to know each other and align our sessions to what works best for you.
Fill in the details below so I can understand your needs and schedule our session accordingly. The information shared is completely confidential.

Personal Information

Name

Age

Email

Contact Number

Place/Address

Counseling History

Have you had therapy/counseling before?

Have you had therapy/counseling before?
A
B

Are you currently on any medication or have you been on medication in the past?

Are you currently on any medication or have you been on medication in the past?
A
B

Any particular reason for choosing therapy now?

What are your expectations and/or goals from therapy?

How did you hear about me?