First Name *

Email *

WhatsApp Number *

Age *

Which country do you live in? *

Your ethnicity *

Reason for Seeking Counseling *

Relationship Status *

What are the 2 issues that are bothering you the most? *

When did this begin? Give dates if possible. *

What do you hope to accomplish in counseling? *

Are you currently experiencing any chronic pain? If yes, please describe. *

What significant life changes or stressful events have you experienced recently? *

Have you received psychological, psychiatric, or counseling services in the past? If yes, what was your concern at the time and what was the result? *

List any psychiatric medications you may have been prescribed. *

Do you pray all five daily prayers? *

Do you fast Ramadan? *

Do you pray sunnah Prayers? *

Do you fast extra days outside Ramadan? *

Hijab/ Niqab/ No Hijab *

Converted to Islam or born in Muslim family? *

Have you ever used drugs or alcohol? *

What are your main worries and fears? *

Check the box below to proceed *

Email Coaching

Subscription

$50

Terms & Conditions to agree:

I undertand a coach will reach out to me within 24 hrs & Its an email service.
I agree to not file a claim against this charge and trust that Positive Islamic Psychology Coaching will be fair in their final decision on reimbursement.
I understand and accept that all TIPS and Sponsored Sessions will be used specifically to support brother Gabriel for his dawa projects including Positive Islamic Psychology Coaching if I decide to support during the payment process.

I have read and agree to the terms here and on the policy page of Positive Islamic Psychology Coaching.

Cancellation Policy

No refunds are provided.

To cancel your membership for the following month, email us at [email protected] at least 5 days before the next billing date.

Cancellation Policy

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