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Counseling request form

Hello, I am Kinnari Abhyankar (counseling psychologist).

This form is designed to help me get to know you and understand how I can best support you. Please answer the questions as fully and honestly as you're comfortable with.

Please Note:
- I am currently accepting a limited number of clients.

- All sessions are conducted via secure video calls and will last approximately 45–50 minutes.

- At this time, I am unable to offer counseling to individuals with a diagnosed psychiatric condition or to my personal acquaintances, including friends and relatives.

- The number and frequency of sessions will be discussed and mutually agreed upon during our first meeting.

Submitting this form does not automatically qualify you for counseling services. It is the first step in determining if we are a good fit to work together. All details are kept strictly confidential.

Demographics

Have you previously taken the services of a Mental Health Professional (Psychologist/ Psychiatrist)?

If yes, please mention their designation (Psychologist or Psychiatrist), the duration of treatment and the reason for termination. If you have visited more than one Mental Health Professional, feel free to mention separately.

Reason for seeking therapy (Optional)

Please briefly describe the concerns or issues that brought you to therapy.