Therapy with Nethra - Client Waitlist Form 

**Please note that my slots are currently full and this form is a waitlist. I will reach out to you once I have an available slot. If you want to start therapy right away, I will try my best to reach out with referrals to trusted colleagues that have availability.** 

Hi, I'm Nethra. Thank you for your interest in working with me. 

I am a trained psychotherapist and RYT200-certified yoga practitioner, offering virtual care from Bangalore, India. I work with clients globally and in India -- I am fluent in English and well-versed in Tamil and Telugu. I work with a range of concerns, including but not limited to: anxiety related issues, trauma, individuals with marginalized identities, neurodivergence, interpersonal concerns, etc. 

Please fill out this form in order for me to gain an understanding of you and your current circumstances. You can expect a response from me within 3 working days, after which we will set up a free 15-minute initial consultation.

To learn more about my work, please visit: www.therapywithnethra.com. If you have any queries, feel free to email me at therapywithnethra@gmail.com or WhatsApp me on +918072382019. 

I look forward to being a part of your healing journey! 

**All information provided on this form is completely confidential and will not be shared with anyone else. If you decide not to schedule a session after the consultation, all your details will be deleted from my database.**

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Email *
When are you interested in starting therapy?  *
Name *
Phone number (So I can reach out to you after you fill out this form). If you prefer to reach out over email instead, please indicate that here.  *
Where are you located? (City, State, Country)  *
Age *
Pronouns *
Gender *
Are you a previous client of mine?  *
What services are you interested in?  *
Required
What brings you to therapy?  *
Is this your first time reaching out for therapy?  *
Have you ever received a psychiatric diagnosis? *
Are you currently on any psychotropic medication? If no, write N/A. If yes, please mention the medication, dosage, and duration of treatment.  *
Have you ever experienced suicidal ideation, fantasies of death, and/or attempted to act on these desires? 
 *
Have you ever engaged in self-harm without the intent of suicide? *
Please offer the name, contact number, and your relationship with a contact who I can reach out in case of an emergency. *
What is the frequency of sessions you are looking for?  *
What language(s) are you comfortable in?  *
What have your past experiences in therapy been like? What did you like or not like about your previous experiences? 
Is there anything in specific that drew you to working with me? 
Preferred form of contact  *
How did you learn about my practice?
 *
Standard rates for 60 minute Individual Therapy Sessions
Within India INR 2,000 
Outside of India USD 40

Are you seeking a sliding scale (range lower than standard rate) spot? 

Please note that I only have limited spots and these are primarily for individuals from marginalized backgrounds (class, caste, gender, sexuality, disability). 
 *
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