PFD Intake Form Group C - High School Students
Name *
Email id *
Contact number *
Which grade are you in? *
What do you want to talk about here? *
Do you want to explore art/activities in order to deal with stress? *
Answer the following from your perception
Choose one option for each question
With a new experience you usually - *
When you read a story you’re more likely to - *
Would you rather? *
What kind of teachers do you tend to like? *
With assignments and projects, do you get them done *
Do you prefer to spend your time with *
Do you tend to *
Pick one - *
When processing information do you *
Do you have *
Choose one. You are - *
You are more of a _____ person. *
Do you tend to *
When under pressure do you tend to - *
On a scale of strongly agree to strongly disagree, respond to these statements
I have anxiety about the exams being cancelled *
Strongly agree
Strongly disagree
I’m worried about college admissions/admission to higher education of choosing *
Strongly agree
Strongly disagree
I feel pressured by peers and elders *
Strongly agree
Strongly disagree
I feel the loss of connection with my social group *
Strongly agree
Strongly disagree
Anything else you want to share with us -
Consent Form for Parents
Hello,

Prior to your child/ward participating in the support group, it is important that the parents/guardians understand the confidentiality code. In order for this support group to work, it’s imperative to have a strong relationship of trust amongst the participants and the moderator/child psychologist. This ‘zone of safety’ can only be achieved when there is enough privacy for all the participants.

Having said that, in cases of certain concerns and red-flags like - substance abuse, self harm/suicidal ideation etc, the parents/guardians of the child need to be informed; and will be informed in a timely and appropriate manner. Such information will also be conveyed keeping in mind privacy of the child(ren) and the parents/guardians, and hence cannot be reproduced anywhere else. And the moderator/child psychologist cannot be quoted/cited for their opinions/feedback expressed within the bounds of aforementioned confidentiality.

We need you to sign this consent form, that will signify that you have read and understood the contents of the intake form, as well as the terms of confidentiality listed.

I have read and understood the contents of the intake form, as well as the context and terms of this parental consent form.


Name *
Relationship with the child *
Contact/WhatsApp number of the parent/guardian *
Email id of the parent/guardian *
Registration fee
Although the Support Group sessions themselves are free of charge; there’s a registration fee of 50 INR or above (pay as you wish) in order to cover operational costs for the organisation. Scan the QR code below using payment apps eg - Gpay, Paytm, PhonePe etc; and once the payment is done, please mention the UPI transaction ID in the required section after.
QR code for payment
Enter UPI transaction ID *
Submit
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