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.
Legal & Court Disclaimer: By booking with Positive Islamic Psychology Coaching, you agree that our services are strictly limited to life coaching and Islamic advisory. We do not provide legal advice, do not write or submit documents for legal use, and will not be involved in any legal, court, or dispute-related matters. You agree not to request or attempt to involve us in any legal proceedings, directly or indirectly.
I confirm that I have read and agree to the full Policy Page of Positive Islamic Psychology Coaching before booking.

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

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