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Counselling Registration Form

           We are happy that you took the initiative to contact us to discuss about your problem. We request you to send emails with the following details in the prescribed format provided.

  • Name
  • Age
  • Sex
  • Educational qualifications
  • Employment status
  • Nature of job
  • Marital status
  • Ordinal position
  • Family details
    • Parents
    • Siblings
    • Spouse
    • Children
  • Full postal address
  • State
  • Country
  • Telephone No
  • e-mail
  • Interests
  • Extracurricular activities
  • Primary problems / Complaints
  • Free expression without any barriers (Comprehensive Details of the problem, when it started, identifiable / suspected causes, to what extent it has affected your functional level, associated feelings and emotions, solutions sought, its results)

Supplementary Counseling Registration Form

Name :
Age :                                           Sex : Male Female  
Employment              Others          
Unemployed                 Others          
Qualification              Others          
Marital status
Country  
State or District
Family Details
Ordinal Position
Sibling Information
Number of Elder Brother(s)
Number of Elder Sister(s)
Number of Younger Brother(s)
Number of Younger Sister(s)
Interests
Extracurricular activities

Please Tick your Mental States

Depressed

Anxious

Disturbed Mood

Lack of Concentration

Strained relationship

Alcoholic

Drug Addiction

Obsessive-Compulsive

Lacking Assertiveness

Unable to Communicate

Hyperactive

Jealous

Feeling Inferior

Delusions/Hallucinations

Sexual Problems

Free Expression Area; Convey all your feelings, experiences, problems simple or complex, without any barriers in detail.



E mail for Us to Contact you     

How did you Find us           

    

All informations filled in above will be guarded secrets. Please send your mail both to Email :rmanojcp@gmail.com ( or ) rmanojcp@yahoo.co.in(or) rmanojcp@30gigs.com
MISSION SUCCESS
PLOT NO 20, DOOR NO 7,
GANESH NAGAR 4TH STREET,
ADAMBAKKAM,CHENNAI 600088,
TAMIL NADU STATE, INDIA

Tel: 91-044-22532176, Mobile: 9444112608

Email :rmanojcp@gmail.com ( or ) rmanojcp@yahoo.co.in(or)rmanojcp@30gigs.com
URL :http://oocities.com/rmanojcp

MISSION SUCCESS