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mental health managment
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Intake form
Help us serve you better
Name
*
Email address
*
What is your age group?
Select
Under 10
10-12
13-15
16-18
Above 18
What is your relationship to the child?
Please select at least one option.
Parent
Teacher
Community Member
NGO Worker
What are the primary challenges you believe the child is facing?
Please select at least one option.
Academic Stress
Emotional Distress
Social Challenges
Family Responsibilities
Lack of Focus
What specific mental health services are you interested in?
Please select at least one option.
Focus Enhancement
Emotional Resilience Training
Positive Mindset Development
Stress Management Techniques
Workshops for Teachers
Have you previously participated in any mental health programs?
Select
Yes
No
What is your preferred method of communication?
Please select at least one option.
Phone Call
Email
In-Person Meeting
Online Video Call
How did you hear about us?
Please select at least one option.
Social Media
Word of Mouth
School
NGO
Online Search
What are your expectations from the MHM program?
Additional questions or comments
Please confirm that you are not a robot.
Submit
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