Client in-take form

Name *

First Name Last Name

What's your e-mail address? *

example@example.com

Location *

Street Address

Street Address Line 2

City State / Province

Country

Date of birth *

Date

Gender

Female Male

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

Yes No

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

Single Married Divorced Separated In a relationship

Employment status

Employed or Self-employed Out of work and looking for work Out of work but not currently looking for work Homemaker Student Retired Unable to work

How did you find out about Heal with Sumit?

Have you been abused?

Yes No Not Sure

Who was/ is your abuser?

Parent Spouse Work colleague/boss Partner/girlfriend/boyfriend

Select type of abuse

Physical Emotional/verbal Mental/Psychological Sexual Financial All of above

Contact status with the abuser

Living together In contact No contact On and off Contact 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?

How would you rate your:

	Terrible	Bad	OK	Good	Great
Mental health
Physical health
Ability to make decisions
Motivation level
Positivity level

What is your biggest challenge at the moment?

How are you currently managing your challenges / traumas?

Have you had any professional help (therapy/coaching)?

Yes No Yes, but it didn’t help

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

Free session $ 10.00

For new clients only. Handling fee $10 applied (non-refundable)

1:1 online session $ 106.00

One 1:1 online session

4 Week PTSD Recovery Program $ 371.00

4 online 1:1 sessions of 1 hr each to recover from PTSD/CPTSD symptoms. $350 + Handling fee

7 session sign-up $ 742.00

7 online 1:1 sessions. $700 + Handling fee

Total $ 0.00