TST || Your Trusted Psychologists

The Social Therapist | Your Trusted Psychologists

Thank you for embarking upon your mental health journey with us. Please fill in the form below to allow us to get to know you better before we begin sessions. All information shared by you will be kept completely confidential and safe. Note: All sessions will take place online through audio/video calls, except in Gurugram and Jaipur where in-person sessions are available (once a week only).
Client Name*

First NameLast Name
Preferred pronouns
s/he/they/other
Current Address*

Street Address

Street Address Line 2

Address, CityState / Province

Country Country
Age
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Cell Phone*

Country CodePhone Number
WhatsApp Number

Country CodePhone Number
Preferred Method of Contact*

Cell PhoneE-mail
Highest Level of Education*

PhD/DoctorateMasters/Post Graduate DegreeBachelors/Graduate DegreeHighSchool (10th/12th Standard)Other
Current Occupation*
If you're currently employed, please mention your industry/role
Relationship Status
Relationship Status*

SingleIn a RelationshipComplicated/SituationshipMarried/PartneredSeparated/DivorcedWidowedOther
How do you currently describe your sexual orientation?*

Straight/HeterosexualGayLesbianBisexualPansexualQueerAsexualQuestioningPrefer not to SayOther
How do you currently describe your gender identity?*

WomanManHijraTransgender womanTransgender manNonbinaryGenderqueer/gender non-conformingPrefer not to sayOther
How did you hear about me?*

Social Media - InstagramSocial Media - FacebookSocial Media - LinkedIn/TwitterSocial Media - Ads (FB/IG)Website (shiromichaturvedi.com)Website (thesocialtherapist.in)Mental Health DirectorySearch Engines (Google/Maps)ReferralOther
If you were referred by someone, please specify their details:

First NameLast Name
Name*

First NameLast Name
Phone Number*

Country CodePhone Number
Relationship*
Medical and Family History

This section is optional, depending upon your comfort in sharing these details via a form.
Please check all the apply

NoneAllergiesAnemiaAnxietyArthritisAsthmaHypertrophyCancerCronary Artery DiseaseCOPD (Emphysema)DepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHypertensionIrritable Bowel DiseaseLiver/Renal DiseaseMigraine HeadachesPeptic Ulcer DiseasePCOS/PCODSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Family history

AdoptedAlcoholismAllergiesAsthmaCAD (Heart Attack)CancerCVA (Stroke)DepressionDiabetesEczemaHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOther
Mental Health History
What are your current concerns?*
Mention the personal/professional/social/relationship/health/other concerns you're seeking help for primarily in this section
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
What type of therapy are you looking for currently?

Individual TherapyCouple TherapyFamily TherapyUnsure
What is your budget for therapy?*

Rs 4000 +Rs 3000 - Rs 3500Rs 2500 - Rs 3000Rs 2000 - Rs 2500Rs 1500 - Rs 2000Rs 1000 - Rs 1500Other
Additional comments or concerns
Mention any preferred therapist/therapy modality here
*Your acceptance below indicates that the information you have provided above is truthful.
Date

DayMonthYear
Date
Should be Empty:

The Social Therapist | Your Trusted Psychologists

Medical and Family History

Mental Health History