Direct Client In-take Form for Online Sessions with all therapists at Silver Linings
Hello,

Thank You for choosing Silver Linings: Guidance & Counselling Centre to assist you in the counselling process. In order to conduct our online sessions smoothly with you, we require you to fill in the following basic details. These details will be kept confidential at all times and used only for the purpose of counselling.

Please Note: 

Allow us 2 working days, from the time of filling the form, to reach out to you and assist you with the session scheduling and session fee details. Alternatively, you can call us on +91 8830245380 to book a session after filling this form. 


Thank You
Shobhika Jaju
Founder - Silver Linings: Guidance & Counselling Centre
[Psychologist - Psychotherapist]
[+91 8830245380 - Office number]
 
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Name *
Age (in years) *
Date of Birth *
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DD
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YYYY
Gender
Pronouns (How may we address you?)
Address: *
Contact Number: *
E-mail address: *
Relationship Status (Optional):
Educational Qualification: *
Current Occupation (Optional):
Languages Known (Optional):
Medical History (if any):
Presenting Concerns (Reasons for opting for counselling): *
Preferred Day of the Week & Time for the Therapy Sessions [Please provide at least 3 options]             **Please note that Shobhika Jaju is not available on Sunday for sessions. However, we have other therapists at Silver Linings, who are available through the week and can offer therapy slots immediately. To know more about our other therapists, please visit, www.silverliningsgoa.com  *
Choose your therapist (To know about your therapists, visit silverliningsgoa.com) *
How did you find out about us? *
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