Te’Airra Sharma Enterprises LLC Client Referral
Client name
*
First Name
Last Name
Email
*
Mobile
*
Age
*
Geographical Location
*
City/State
City
State / Province
Country
Employment status
*
Please Select
FT employed
PT employed
Self-employed
FT parent
FT Student
PT Student
Unemployed
Other
Religion
*
Please Select
Muslim
Hindu
Buddhist
Christian
Sikh
Jewish
Catholic
Other
1st lanuage
*
2nd lanuage
Is the client a parent?
*
Please Select
Yes
No
Does the client have a healthy support system?
*
Please Select
Yes
No
Is this referral is being made on behalf of someone other than the client?
*
Please Select
Yes
No
If you responded “Yes” to the previous question, does the client know that they are being referred to Te’Airra Sharma Enterprises LLC for potential services?
*
Please Select
Yes
No
N/A
Referred by
*
Please Select
Friend
Family
Self
Business
Other
N/A
Referral Name (Type N/A if you are the client)
*
Relation to client
*
Please Select
Self
Parent
Sibling
Daughter
Son
Sister
Brother
Other family
Friend
Colleague
Other
N/A
Contact number
*
Reason for referral
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Do you have any special needs to consider and/or risks identified that we should know about?
*
What is the Primary Mental Health Challenge That You Need Mentoring and/or Educational Support?
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Depression
Anxiety
Stress
Suicidal Thoughts
Parenting Conflicts
Marriage Conflicts
Identity Crisis/Confusion
Rejection
Abandonment
Grief/Loss
Anger
Trust Issues
Fear of Using Your Voice
Other
Services Requested
*
1 on 1 Mentoring
Group Mentoring
Emotional Wellness Coaching
Educational Support for spirit, soul, and/or mental health literacy
Mental Health Mentoring Consultation
Prayer/Prayer Strategies
Other
Client availability
*
Rows
Tues
Weds
Thurs
AM
PM
Data protection
*
Client understands and accepts that their information will be kept securely until it is no longer required to assist them or by law. Permission is granted to Te’Airra Sharma Enterprises LLC and its partners to contact the client by their identified preferred contact method.
Acknowledgement
*
Client understands and accepts that services offered by Te’Airra Sharma Enterprises LLC provide solutions and strategies based on the founders personal success through lived experiences and prayer using Biblical principles. We do not provide mental health diagnoses for clients. Our services are not a substitute for professional care, they are complimentary and supportive. If you are currently seeing a mental health provider, please continue to see your licensed professional counselor in conjunction with these services. By checking this box, I acknowledge that I agree with and understand the acknowledgement statement provided by Te’Airra Sharma Enterprises LLC.
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