Language
English (US)
Ukrainian
Application for Free Mental Health Counseling
* All data that you provide in the questionnaire is not subject to disclosure and is used solely for the purpose of effectively working on your request.
Name
*
First Name
Last Name
Age (if mental health help is needed for a child - indicate the age of a child)
*
I am a citizen of Ukraine
*
Yes
No
What negative state do you want to get rid of?
*
Grievance
Apathy, depression
Anger, irritation, aggression
Guilt
Fear, anxiety
Sadness, melancholy
Exhaustion
Helplessness, powerlessness
Other
Rate from 1 to 10 how much the question (emotion) makes you feel uncomfortable (where 1 means almost no discomfort, 10 means very strong discomfort)
*
no discomfort
1
2
3
4
5
6
7
8
9
very strong discomfort
10
1 is no discomfort, 10 is very strong discomfort
Briefly, in your own words, describe your issue that you want to work on with psychologist
I want free consultation with the psychologist (name of psychologist):
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Zip code
*
I am warned and agree that in case of providing false information about my health or condition, psychologist does not bear any responsibility for the results of the session.
*
Warned and agree
I do not take psychotropic, hallucinogenic, narcotic and other psychoactive medications that affect the functioning of the nervous system
*
Confirm
In last 3 years I have not had any suicide attempts.
*
Confirm
How did you know about us?
*
Instagram
Facebook
Linkedin
Recommendation
Other
Submit
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