Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Personal Information of the Referrer: LayoutYour Full Name *Your contact no. *Your Relationship to the Person Seeking Therapy *Your Email Address *NextInformation about the Person Seeking Therapy LayoutFull Name of the Person Seeking Therapy *Gender *SelectMaleFemaleDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact no. of the Person Seeking Therapy *Email Address of the Person Seeking Therapy *Address of the Person Seeking Therapy *NextBackground Information: LayoutOccupation (if applicable)Marital Status: *SelectMarriedSingleLiving Situation (Alone, with Family, Roommates, etc.): *Briefly describe the person's current support system *Reasons for Seeking Therapy *NextWhat specific issues or challenges does the person mention or you observe that bring them to therapy?AnxietyDepressionSocial AnxietyRelationship IssuesTraumaGrief and LossAddictionOther (Specify)*SpecifyNextPlease provide any additional details about the person's emotional state or concerns:NextHas the person received therapy or counseling before? *YesNoPlease provide a brief history *NextMedical and Psychological History: Is the person currently managing any medical conditions or taking any medication? *YesNoPlease Specify: *NextHas the person ever been diagnosed with a mental health disorder? *YesNoPlease specify: *NextGoals for Therapy: What are the primary goals for the person seeking therapy? *Coping with stressImproving relationshipsOvercoming specific fears or phobiasManaging emotionsEnhancing self-esteemOther (Specify)Please specify: *NextIs there anything specific the person hopes to achieve through therapy?NextAdditional Information: Is there any information about the person's cultural or religious background that you feel is important for the therapist to know?Are there any specific preferences or concerns regarding the therapeutic process that you or the person have?NextConsent and Agreement: I understand that the information shared in therapy is confidential, with certain exceptions. *YesNoLayoutSignature *(Type your full name as a digital signature)Date: *Submit
