Type of Counselling
Name:
Age:
Gender:
Edu. Qualification:
Marital status:
City:
Phone number:
Email:
You are consulting for:
Did you consult anyone before for the mentioned problems?
1. Yes (specify duration of treatment, give a brief account of treatment received so far)
2. No
Please select any five dates below
How did you come to know about this website?
1. Through a client
2. Through a clinician
3. Through internet
4. Other Sources
Since how long you have been facing these problems (specify duration in days, weeks, months or years)
Briefly describe your problems:
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