PEACE HUB SERVICE 
 Counseling  Appointment                                                            www.peacehubinternational.com
 
Email *
Informed Consent and Authorization for Services
I hereby make application to receive services from Peace Hub Counseling and Well- Being Centre and I have been informed about fee and limits of Confidentiality. I understand that all information obtained will be maintained in a confidential manner. I further understand that no information shall be released or obtained without my written consent except in the condition of ' duty to warn ' as detailed in the limits of confidentiality. My fee Rs.1000
for 1 hour has been explained and found acceptable.




WE RESPECT YOUR PRIVACY 
Place *
Date *
MM
/
DD
/
YYYY
Age *
Gender *
Email id
Contact Number *
Whatsapp Number
Name  of Parent/ Husband/Partner  *
Select the type of service you want *
Required
Counseling Mode *
Required
Counseling Appoinment Fee Rs.1000

Pls Note : Counseling Fee: Rs 1000 for 1 hour. Fees are charged only for the time taken for counseling. The appointment fee will be deducted from the amount of total time taken for counselling. Subsequent fees are payable after the session.


Clear selection
Your Payment Method 
Follow - up reminder reference *
Google Map
Peace Hub , A Centre for Human Well-being

https://maps.app.goo.gl/kzr9YzXF3qez4bNm9
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms