Intake Application

Schedule Your Therapy Intake

Appointment Application Form

Please fill out the intake details below. All information is handled with strict privacy and care.

1. Contact Information

First Name *

Last Name *

Email Address *

We will send session confirmation details here.

Age *

Phone Number / WhatsApp *

Include country code if outside India.

Preferred Language *

ID Proof (Optional)

Optional identity verification. Accepted formats: PDF, JPG, PNG (Max 5MB). Handled strictly under ethical psychological privacy standards.

Click or drag file here to attach an optional ID proofPDF, JPG, or PNG up to 5MB

2. Service & Scheduling Preferences

Preferred Psychological Service *

Session Mode

Preferred Date

Subject to availability.

Preferred Time Window

3. Tell Us What You Would Like Support With

Primary Area of Focus / Concern *

Additional Notes or Questions (Optional)

I understand that Mentisara provides structured, person-centred psychological services. I consent to having Mentisara process my contact details securely for scheduling purposes. *

Your information is encrypted and never shared with third parties.

Ethics & Privacy

Secure and private handling of personal details.

24-Hour Response

Prompt coordination via email or phone.

Direct WhatsApp

Prefer quick messaging? Chat on WhatsApp