Details about you

Your Name *

Your Age *

Your Occupation

Your Education Qualification

Your Mobile Number *

WhatsApp Number If different from mobile

Address

Street Address

City

State

Country

Postal Code

How did you come to know about us? *

Preferred Language for Consultation *

Concerns (Select all that apply) *

Please describe your concerns in detail (2-3 lines) *

When did these concerns begin? *

Have you seen a mental health professional before? *

Any past diagnosis, health conditions, or current medications? (Child/Self)

Any known allergies? (Child/Self)

What are the individual's strengths or interests? For a child, what do they enjoy or are good at?

Your Journey to Our Clinic

Help us understand the path that brought you here.

Have you consulted other professionals ( Family Physician / Pediatrician etc ) for these concerns before coming here?

Previous Consultations (If Yes) Please list details chronologically: When, Who (Provider/Healer), and What was the outcome (What was suggested? Was it helpful?). Example: Jan 2024, Pediatrician, Suggested wait-and-watch approach, Not helpful.

What made you decide to come to our clinic specifically?

What other approaches have you tried? (Select all that apply)

Your Understanding & Beliefs

Your perspectives help us communicate better.

What do you believe is the main reason for the difficulties? (Select all that apply)

How do family members view these concerns? Family View Score

How does your community generally view children with developmental differences?

Are there any cultural or religious practices important to your family's health decisions?

What concerns you most about seeking therapy?