Ask For Help

Name *

First

Last

Email *

Do you identify yourself as a queer? *

We have queer affirmative therapists and folks in our NGO. So, the question isn't to judge but rather get a better understanding of where you are coming from

Date of Birth *

Contact Number *

Contact Number of your Parent/Guardian *

What kind of support you are seeking *

Emotional Support
Counselling/Therapy
Support Group
All of the Above

Does anyone from your family know what you are going through? *

Kindly choose the preferred age group of your counsellor. *

20-30
30-40
40-50

Note: Age group doesn't reflect the experience of the therapist.

Would you prefer a male therapist or a female therapist? *

Male
Female
Prefer Not To Say

If you are seeking Professional Mental health support, what is your budget per session? *

500-1000
1000-1500

There are many people who can't afford therapy due to low family income but strongly need it. Hence, we have kept the option for the budget. Your budget isn't for the quality of our service. We shall try to help you to the best of our abiliities.

Can You Afford To Pay For Our Professional Mental Health Service? *

If no, kindly state your reason 🙂 *

If you can, enter NA

Please describe what issues you are facing. So, we can provide you the best help 🙂 *

Do you think of harming yourself or attempting suicide? *

Have you been diagnosed with any mental illness? *

Please upload your medical certificate if you have been diagnosed

Click or drag a file to this area to upload.

Are you on any medication? *

Kindly mention the names of your medicines *

If you are not taking any medicines, enter NA

How Did You Get To Know About Our Foundation? *

Consent *

I agree

In a clinical case, i.e. if the client is suffering from a mental illness, or is diagnosed with one; his/her family will be informed about the same after their consent. The case shall be then transferred to the near hospital or a clinic of the clinical psychologist/psychiatrist. If the client wishes to continue the therapy with the NGO, the same shall be entertained. We also will be in touch even after the case has been transferred to ensure that quality treatment is being provided.

Mental Health Support Form

You are not Alone

We care for you