Khair Initial Consultation Intake Form

Thank you for completing this intake form.

This form is designed to help us prepare for your 15-minute consultation and make the most of our time together. Please share any relevant questions, concerns, personal circumstances, or background information you would like to discuss. The more information you provide, the more focused and beneficial your session can be.

Please also indicate which event you will be attending so we can be prepared for your consultation.

All information provided will be used solely for the purpose of preparing for your session.

Full Name

First NameLast Name

Email Address

example@example.com

Age

Marital Status

Occupation

Which event will you coming after?

What category best describes your situation?

Briefly describe your situation. (Be as clear and honest as possible. The more context you provide, the more beneficial the answer can be.)

How long has this issue been ongoing?

Have you previously sought support for this issue?

If you sought support before, from who? (Therapy / Imam / Mentor / Other)

Are you currently experiencing?

On a scale of 1–10, how urgent does this feel?

What outcome are you hoping for from these sessions?