NAME


AGE


DATE OF BIRTH


SCHOOL/COLLEGE /UNIVERSITY NAME


GRADE


FATHER’S NAME


CONTACT NO


EMAIL ID


MOTHER’S NAME


CONTACT NO


EMAIL ID


ADDRESS


CITY


NUMBER OF FAMILY MEMBERS


NUMBER OF SIBLING


ACADEMIC PERFORMANCE
EXCELLENTVERY GOODGOODAVERAGEBELOW AVERAGE

Are you concerned about your child's social media usage?
YESNO

If yes, please explain your concern


Please describe the problem you child has or had previously.


Parental Concerns


Is there anything else you would like to add about your reasons for seeking services ?


What have you been told by doctors, therapists, teachers, or others about your child’s problems?


WHAT DO YOU EXPECT FROM THIS COUNSELING SESSIONS ?

NAME


AGE


GENDER
MALEFEMALEOTHER

DATE OF BIRTH


CONTACT NO


ALTERNATIVE CONTACT NO


ADDRESS


CITY


PINCODE


EMAIL ID


CURRENT MARITUAL STATUS
SINGLEMARRIEDSEPARATEDDIVORCED

EMPLOYMENT
FULL TIMEPART TIMESELF EMPLOYED

DESIGNATION


WHAT DO YOU EXPECT FROM THIS COUNSELLING ?


HAVE YOU VISITED ANY COUNSELLOR / PSYCHOLOGIST OR ANY OTHER PROFESSIONAL BEFORE ?
YESNO

REQUEST FOR
INDIVIDUAL THERAPYCOUPLE THERAPYFAMILY THERAPY

PLEASE DESCRIBE ANY OTHER EXPERIENCE YOU HAVE / HAD FACED PROBLEM WITH

ADDITIONAL COMMENT OR CONCERNS