Client in-take form

Name*

First NameLast Name
What's your e-mail address?*
example@example.com
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of birth*

MonthDayYear
Date
Gender

FemaleMaleOther
Are you a new client? Please select yes if you are here for the first time.

YesNo
As your guide, it is important for me to understand how you process and view your traumas and yourself in particular.

Every person has their own unique and personal way of interacting with their challenges and traumas.

These questions will hopefully provide a means for me to understand you and your current position more closely and thus enables me to guide you to heal in the best way.

Please take some time to answer these questions as thoughtfully and clearly as possible.

These questions are designed to be “mulled over” and to stimulate your thinking on items that may have been automatic in the past.

If you have any queries please let me know and we can discuss them.
Relationship status

SingleMarriedDivorcedSeparatedIn a relationshipOther
Employment status

Employed or Self-employedOut of work and looking for workOut of work but not currently looking for workHomemakerStudentRetiredUnable to workOther
How did you find out about Heal with Sumit?
Have you been abused?

YesNoNot SureOther
Who was/ is your abuser?

ParentSpouseWork colleague/bossPartner/girlfriend/boyfriendOther
Select type of abuse

PhysicalEmotional/verbalMental/PsychologicalSexualFinancialAll of aboveOther
Contact status with the abuser

Living togetherIn contactNo contactOn and offContact because of child / children
How long have you been abused for (in years)?
Put 1 if less than a year
Describe you PTSD symptoms (if any)
How long have you been experiencing PTSD symptoms for?

What is your biggest challenge at the moment?
How are you currently managing your challenges / traumas?
Have you had any professional help (therapy/coaching)?

YesNoYes, but it didn’t helpOther
What outcomes are you hoping to get from session(s)?
Is there anything you would like to share, which may help me understanding your current situation?
IMPORTANT NOTE
- All the necessary information shared by you during the entire process will be treated as confidential and will not be shared with anyone.
- After submitting the form you will be redirected to the page to schedule the session.
- You will receive a confirmation email from me, please make sure to reply to that email to confirm your attendance.
- You agree to pay for the program/package/ handling fee in advance (Select below).
- The fee is non-refundable unless bought with the money-back guarantee.
My Products
prevnext( X )
1:1 online session $106.00
One 1:1 online session $100 + Handling fee

Pack of 4 online sessions$371.00
Package of 4 sessions $350 + Handling fee

Pack of 7 online 1:1 sessions$636.00
7 online 1:1 sessions. $600 + Handling fee

Total $0.00
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