Connect with a counselor – Afiyah Counsel & Care

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Name

Age

Gender

Marital Status

Nationality

Country of Residence

Email Address

Contact Number

Have you previously received any type of mental health services? (psychotherapy, psychiatric services, counselling)

Yes No

Please elaborate the mental health services you availed in the past

If yes, have you been ever on psychiatric medication? If yes, please list.

Please list any difficulties you experience with your appetite or eating problems.

Are you currently experiencing anxiety, panic attacks or have any phobias?

Present complaint/Problem

Order of Birth

Eldest Middle child Youngest

Number of Siblings (if any)

Any history of complications at birth?

Yes No

Any history of complications during childhood?

Yes No

Any history of psychiatric illness?

Yes No Never Consulted

Any history of psychiatric illness in parents? *

Yes No Maybe

Any history of academic complaints in School/College?

Yes No

How did you hear about us?

Website Social media Emails Word of mouth (Friends,Family,etc)

I have read and understood the terms and conditions.

I have read and understood the refund policy. Please note that, after filling this form, it will be redirected to another page to select an appointment with your counselor.

Connect with our counselors

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