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Client intake questionnaire

What kind of support do you think would help you best with your current problems?

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What kind of support do you think would help you best with your current problems?

Solution-Oriented

Strength and Motivational

Self-Discovery

Behavioural Management

Listener and Venting Out

Personality Development

Conflict Resolution

Relaxation and Mindfulness

Interpersonal/Social Dynamics

Select the languages you are comfortable taking therapy in

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Select the languages you are comfortable taking therapy in

Hindi

English

Marathi

Kannada

Tulu

Other

What kind of personality traits do you prefer in your therapist?

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What kind of personality traits do you prefer in your therapist?

Calm and Reassuring

Direct & Analytical

Humorous & Extroverted

Supportive & Encouraging

5. Understanding Your Concerns (Select all that apply)

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5. Understanding Your Concerns (Select all that apply)

A

Anxiety (Excessive Worry)

B

Persistent Sadness

C

Stress

D

Mood Swings

E

Intrusive Thoughts

F

Unhealthy Eating Habits

G

Attention Difficulties

H

Disruptive Personality Traits

I

Addiction Issues

J

Distorted Reality

K

Trauma or PastDistress

L

Sleep Problems

M

Gender Identity

N

Work Stress

O

Developmental Issues

P

Relationship Problems

Q

Body Image

R

Dissociation

S

Existential Concerns

T

Parenting Struggles

Can you describe your concerns more in details?

On a scale of 1–5, how severe do you consider your mental health concerns to be?

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On a scale of 1–5, how severe do you consider your mental health concerns to be?

1

2

3

4

5

How often have you felt nervous, anxious, or on edge in the past few weeks?

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How often have you felt nervous, anxious, or on edge in the past few weeks?

Not at all

Rarely

Sometimes

Often

Please enter your name

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Please enter your email id

*

Please enter your contact number

*

Please enter your age

*

Please enter your gender

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Please enter your gender

Male

Female

Non-binary

Prefer not to say