Speak Your Mind

Counselling Registration Form

Please read the important information and terms below. If you decide to participate, fill the form and provide your consent.

Important Information & Terms of Service

1Offline at D-252, 1st Floor, Jhilmil Colony, Delhi-110095 or online via Google Meet, WhatsApp, or Phone call (+91-8448025230) — upon mutual agreement.
2Session fees paid in advance: PayTM/GPay +91-8448025230 | Bank A/c: 4235000100259696, IFSC: PUNB0423500, Holder: Jatin Khurana.
3Appointment shall be booked at least 24 hours prior to the session (except in case of emergency).
4The session is non-cancellable; however, it can be rescheduled if informed at least 12 hours before the session time.
5If you are receiving treatment from other medical facilities, I may contact your doctor with your consent.
6Please follow the counselling policies throughout the course of counselling.
7I will only act as a facilitator. Your commitment and dedication will help you overcome situations in life. I hold no responsibility for any circumstances in your life.
8I may refer you to another healthcare provider or counsellor for your betterment — with your consent and with your information de-identified.
9Private and confidential. Exceptions: (1) Legal responsibility to release information. (2) Imminent physical threat to self or others. (3) If you are a child or brought by a guardian.
10Sessions will be audio recorded with your verbal consent. Recordings are for case study and betterment. Transcripts may be used for research with your information strictly de-identified.
11I may present your case at professional conferences to enhance my skills. Your personal information will be de-identified to protect confidentiality.

If you have any concerns, feel free to contact Jatin before filling this form.

Client Information

Fields marked * are required

Full Name *

Email Address *

Age *

Biological Sex *

Religion

Guardian Name (if minor)

Phone Number *

Address *

Type of Family *

Marital Status *

Educational Status *

Occupation *

Socio-Economic Status *

Any other remarks or information you wish to share

Consent & Declaration

I have read and understood all the terms and conditions (Points 1–11), including session format, fees, cancellation policy, confidentiality, and recording policy. I agree to abide by these terms throughout the course of counselling.

I have read the above material and understand its provisions. I understand that the results of counselling vary from person to person and that achieving a positive outcome depends upon my efforts as well as my counsellor's guidance and counselling.

Your information is kept strictly private and confidential.

Healing in progress...