Registration Hey! Help us get to know you better so that we can walk this journey with you Personal Information Full Name Date of birth Gender MaleFemaleNon-binaryPrefer not to sayPrefer to self-describe Please Describe Your Gender Pronouns She/HerHe/HimThey/ThemOther Please Specify Marital Status SingleMarriedDivorcedWidowedOther Contact Number Email Id Socio-Demographic Details Education Level SchoolUndergraduatePostgraduateDoctorateOther Please Specify Education Level Work Nature StudentEmployedSelf-employedHomemakerUnemployedRetired Referral & Session Details: How did you hear about us? InstagramWebsiteFriend/ReferralInstitutionOther How did you hear about us? (if other) Preferred Mode of Sessions OnlineIn-person Preferred Language for Sessions EnglishHindiMalayalam Clinical & Wellness Information: (Optional, but helpful for tailoring your support) Primary concern(s) you're seeking help for: (e.g., anxiety, relationship issues, trauma, life transitions) Are you currently taking any medication or under medical/psychiatric care? YesNo If yes, please specify: Have you previously attended therapy or counselling? YesNo If yes, when and for how long? Any other information you wish to share: Emergency Contact (Optional but Recommended) Name Relationship Phone Declaration & Consent I understand that this form is confidential and the information provided is accurate to the best of my knowledge. I consent to engage in therapy/coaching services with Dee-Cognito under the terms and ethics of psychological practice.
