Let's Match You with the Best Therapist!
Thank you for trusting The Emotional Wellness Initiatives with your wellness journey! Finding the right therapist for yourself can seem like a daunting task and we want to ease the pressure off of you. All you need to do is answer a few short questions below, and we'll match you with the best suited therapist for your needs!
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Email *
Full name *
Your WhatsApp number? *
Date of birth *
MM
/
DD
/
YYYY
Parent / legal guardian name

*
Mention NA if you are not a minor.
Parent / legal guardian contact no. *
Mention NA if you are not a minor.
Gender *
Relationship Status
*
Occupation *
Your location (Town / City & Country) *
What are the issues for which you are seeking help?  *
Required
Current symptoms
Check under 1 to 5 as per the intensity of the symptom.
5 very high - 1 very low.
Leave blank if you do not have the particular symptom.
1
2
3
4
5
Anxiety attacks
Avoidance
Change in Appetite
Unable to concentrate / forgetfulness
Crying spells
Decrease need for sleep
Decreased libido
Depressed mood
Excessive energy
Excessive guilt
Excessive worry
Fatigue
Hallucinations
Impulsivity
Increased irritability
Increased libido
Increased risky behavior
Loss of interest
Racing thoughts
Sleep pattern disturbance
Suspiciousness
Unable to enjoy activities
Any symptom not mentioned in the above list? *
Mention None if you are not facing any other symptom
Have you ever had feelings or thoughts that you didn't want to live / suicide?
*
Do you currently feel that you don't want to live?
*
Any known medical condition
*
Are you currently on any psychiatric medication. *
Are you seeking therapy / counselling for the first time? *
What do you consider to be some of your strengths?
*
What do you consider to be some of your weaknesses?
*
What would you like to accomplish out of your time in therapy?
*
How did you find out about The Emotional Wellness Initiatives? *
Referred by? *
Mention NA if you found us otherwise
Is there anything else you would like to tell us to help us make a selection?
Submit
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