Clone of Oasis Wellness Booking

1
Which country do you live in?Option for the person seeking therapy
Canada
United States
Middle East
Malaysia
2
How old are you?Describe the age of the person seeking therapy
18 years old or above
Between 12 and 15 years old
17 years old
Between 9 and 11 years old
16 years old
Between 3 and 8 years old
3
What led you to consider therapy today as an individual?Describe the what best fit the person seeking therapy.
I feel anxious and/or overwhelmed
I have been feeling depressed
I am hoping to change something in my life
My mental health is impacting my work/school/family life
I am struggling with addiction and/or substance use
I am having relationship difficulties (friendships/family/romantic/more)
I am in an abusive or violent relationship
I have experienced Islamophobia/racism and/or discrimination
I can't find purpose and meaning in my life
I am experiencing grief and/or loss
I have experienced trauma
I have ADHD or ADD
I want to improve my self-confidence and/or self-esteem
I am struggling with my spirituality
I am having suicidal thoughts and/or feel like life is not worth living anymore
I am struggling with intrusive thoughts/OCD
I have been diagnosed with a personality disorder
I need help with sexual desires and issues (e.g pornography or intimacy)
I need suppport as a parent
I have an eating disorder
4
What is your preferred language for therapy?
English
Malay
5
Is there anything else you would like to share with me?
Huge
Large
Normal
Small
Ok
Ok
6
Please enter your contact details* This field is required.
First Name
Last Name
7
Email Address* This field is required.
example@example.com
8
Telephone Number* This field is required.
Please enter a valid phone number.
9
Select Appointment Date
10
Terms and Conditions* This field is required.By booking a therapy session, you acknowledge and agree to the following: • You are responsible for providing accurate and complete information during the intake process. • All information shared during sessions is treated as confidential, in accordance with applicable professional and legal requirements. • Sessions are scheduled for a specific time and duration. Late arrival may result in a shortened session. • I reserve the right to decline or reschedule an appointment if the service selected is not appropriate for your needs. By submitting this form, you confirm that you have read and understood these terms.
11
Cancellation Policy* This field is required.Cancellation & Rescheduling Policy • Appointments must be cancelled or rescheduled at least 24 hours in advance. • Late cancellations or missed appointments may be subject to a fee or may limit future bookings. • Repeated no-shows may result in the inability to schedule further sessions. • If you experience a technical issue or emergency, please contact me as soon as possible. Thank you for respecting the time and care reserved for your session.
12
Thank you for your booking request. This is a free 30 min Consultation. Please wait for confirmation and details once your appointment is approved.
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