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 *

Revert to Islam or born in Muslim family? *

Have you ever used drugs or alcohol? *

What are your main worries and fears? *

Terms & Conditions to agree:

I appreciate and will respect my coach by showing up to my session on time.
I undertand a coach will reach out to me within 3 business days & Its an email service there will be no sessions. (Its a system default please ignore that)
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.

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