Child & Adolescent Mental Health Service

S
Intake form

This form is designed to get a general understanding about you and all the information is kept
confidential.

Name: SHIVAM KHARE Tel_____________________

_______________________
Date of birth: 16TH AUGUST 1994
Email__________________
Age: 26 Gender: MALE
_______________________
Address: 67 NIKHIL BUNGLOWS BHOPAL _

Phone no. (Res): NOT AVAILABLE *All the information is

confidential unless there is
Mobile:9011773091
possibility of risk to safety.
Email: VSHIVAMKHARE@GMAIL.COM
Our work is in keeping
Skype: ________________________________________ with the Indian laws and
regulations.
Zoom:_________________________________________
Parental Consent Signature
Current College/Place of Work: IMT HYDERABAD
(Below the age of 18)
Class/Year (if applicable): __________________________
SHIVAM KHARE
Source of referral: BHAVYA
Your digital signature (18
and above)
Please share your main concerns here: AXIETY ISSUES, _____________________
POLARISED EMOTIONAL OUTBURST EITHER ANGER OR
SAD , FEELS LIKE EMOTIONALLY HIJACKED. COGNITIVE Please send a copy of photo
DISTORTIONS id.

________________________________________________

*Parental Contact Details

We would need to take consent from you parents if you are
below the age of 18 years. We will call them and start therapy
thereafter.