Bengaluru Counselling Camp Registration

1

Participant Information

Full name *

Age *

Gender (optional)

City of residence *

Mobile number *

Email address

I am registering for: *

Myself My child My spouse / partner A family member Someone else

Relationship to participant

2

Parent or Guardian Details

Required for participants below 18 years.

Parent / guardian name *

Relationship to participant *

Mobile number *

Email address

3

Appointment Preferences (Fees 1100/Per Person)

Preferred camp day *

Day 1 Day 2 Day 3 (if applicable)

Preferred time window *

Morning Afternoon Evening Any available slot

Preferred counselling language *

English Hindi Kannada Other

Preferred dates and time windows help us schedule your session but are not guaranteed. Your appointment will be confirmed separately, subject to counsellor availability.

4

Area of Support

Please select the area(s) in which support is being sought. You may select more than one. *

Anything you would like the counsellor to know before the session? (optional)

Please protect your privacy: Do not include a detailed medical history, diagnosis or highly sensitive personal information in this form. These can be discussed privately with the counsellor during the session.

5

Accessibility and Coordination

Accessibility support

Preferred contact method

Phone call WhatsApp Email

Best time to contact

6

Consent and Important Information

Participant / guardian name *

Signature *

Date *

Need Immediate Help?

This programme is not an emergency service. If the participant is in immediate danger or requires urgent psychiatric assistance, please contact the nearest hospital or emergency service. For 24×7 Government of India tele-mental-health support, call Tele-MANAS at 14416 or 1800-89-14416.

53/27 Ramjas Rd, Karol Bagh, Delhi

info@vidyagracefoundation.org

8355851008

Counselling Camp Registration

Bengaluru In-Person Counselling Camp

Participant Registration Form