Client Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Client Intake Form

Nurturing Niche is a therapy platform designed to offer a comforting, mask-free space for individuals in distress. Its goal is to foster genuine, meaningful connections through therapeutic alliances. The platform’s vision is to create a nurturing environment where people can embrace themselves. Additionally, it seeks to build a supportive community that allows users to connect with others who share similar experiences, strengthening social support.

Thank you for taking the 1st step and reaching out! I would request you to fill this form as it allows me to know you better. You can reach out to me via email for further queries. I will be reaching out to you once I have received the form.

Name *

Phone Number *

Email ID *

Gender *

Age *

Occupation *

Preferred Language *

How did you hear about me *

Referral

Other:

Could you briefly explain the reasons which brought you to therapy? *

Have you ever had suicidal thoughts or thoughts of harming yourself? If yes, kindly mention the duration and frequency of these thoughts . *

Have you been previously diagnosed with any psychiatric illness by a psychiatrist or a clinical psychologist? *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms