Intake form

Help us serve you better

Name *

Email address *

What is your age group?

What services are you interested in?

Please select at least one option.

Individual Counselling

Group Therapy

Mindfulness Practices

What is your preferred method of communication?

Please select at least one option.

Phone

Video Call

What are your primary concerns or issues?

Do you have any previous experience with therapy or counselling?

Are you currently taking any medication related to mental health?

What is your preferred appointment time?

How did you hear about pearls of healing?

What is your occupation?

Do you have any specific goals for your therapy sessions?

Additional questions or comments

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Pearls of Healing