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SCHEDULE AN APPOINTMENT
Toggle Navigation
Home
About
Services
Contact us
Privacy Policy
Terms and Conditions
SCHEDULE AN APPOINTMENT
Because your mental health matters.
Because your mental health matters.
You don’t have to go through it alone.
Book An Appointment
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2025-04-11T16:18:44+00:00
Full name
*
Date of birth
*
Gender
*
Male
Female
Other
Prefer not to say
Contact Number
*
Email
*
Address
*
Emergency contact name
Emergency contact number
Relationship to the emergency contact
Have you been diagnosed with any mental health condition?
Are you currently taking any medications for mental health?
Have you previously seen a therapist or counselor?
Yes
No
What brings you to seek mental health support? (Check all that apply)
Anxiety
Depression
Stress/Burnout
Relationship Issues
Trauma/PTSD
Sleep Problems
Grief/Loss
Low Self-Esteem
Workplace/School Stress
Other
How long have you been experiencing these concerns?
<1 month
1-6 months
1+ year
Several years
Do you have a strong support system (family, friends, community)?
Yes
No
How would you describe your sleep quality?
Good
Fair
Poor
What are your main goals for therapy or consultation? (Check all that apply)
Managing stress and anxiety
Improving relationships
Overcoming trauma
Developing coping strategies
Enhancing self-confidence
Other
Do you have a history of self-harm or suicidal thoughts?
How would you describe your current emotional state?
Happy
Neutral
Sad
Anxious
Overwhelmed
Do you use any coping mechanisms?
How often do you engage in activities that bring you joy?
Daily
Weekly
Occasionally
Rarely
How often do you exercise or engage in physical activity?
Daily
Weekly
Occasionally
Rarely
Is there anything else you'd like to share about your mental health journey?
Date
Your information is confidential, and we respect your privacy. I understand that my personal information will be kept confidential except in cases where there is a risk of harm to myself or others. I consent to receiving mental health consultation and understand that this is not a substitute for professional medical treatment.
*
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