Appointment Request

JavaScript tidak didayakan dalam penyemak imbas anda, jadi fail ini tidak boleh dibuka. Dayakan dan muatkan semula.

Appointment Request

Dear Client/ Caregiver,

Thank you for choosing STEPS Center for Mental Health. We value the opportunity to serve you. Kindly fill the form below to set up an appointment with Dr Rastogi. This form will not take more than 5 minutes to complete.

Once we have received your details our team will contact you to provide important information regarding your appointment with Dr Rastogi.

In the meantime we can be reached at +91 96672 22154 or at contact@scfmh.com incase of any questions or clarifications. We are available between 10 am and 6 pm, Monday through Friday and 9 am to 5 pm on Saturdays.

Log masuk ke Google untuk menyimpan kemajuan anda. Ketahui lebih lanjut

E-mel *

Your Name (the person completing this form) *

Your phone number (to schedule the appointment) *

Relationship with the client (of the person completing this form) *

Parent

Guardian

I am the client

Lain-lain:

Name of the client *

Age of client *

School name and location *

Please choose a reason or reasons for which you are seeking this appointment *

Psychiatric evaluation and follow up

Safety evaluations

Psychological testing

Mental health assessments

Individual, family and group therapeutic interventions

Consultations with schools or other child serving agencies

Emergency consultations

Lain-lain:

Diperlukan

Please provide a brief description for which you are seeking an appointment (a couple of sentences are sufficient) *

Are there any legal/ custody issues related to the client *

Yes

Is the client currently in therapy ? *

Yes

Kindly share how you learnt about us *

Referred by a doctor

Referred by a friend

Referred by school or school counsellor

Referred by a psychologist

Through an internet search

Articles in the newspaper/ media

Lain-lain:

Referred by (kindly share the name of the person or doctor who has referred us. Please write NA if this does not apply to you) *

Serah

Kosongkan borang

Jangan sekali-kali serahkan kata laluan melalui Borang Google.

Borang ini telah dibuat dalam Steps Center for Mental Health. Laporkan Penyalahgunaan

Borang