Mahal Us Shifa

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I am registering for myself

ITS ID*

First name*

Last name*

Age *

Gender*

Jamaat *

Jamiaat *

Email address*

Phone number*

WhatsApp number*

Same as phone

Emergency Contact

Full Name

WhatsApp Number

Relationship

Password *

Confirm Password *

What brings you in today? * (select up to 3)

0/3 selected

Anxiety / excessive worryLow mood / depressionStress / feeling overwhelmedRelationship / marital concernsFamily conflict / parenting concernsGrief / lossTrauma / past experiencesAnger / irritabilityDevelopmental / behavioral concerns of childhood or adolescents — ADHD, autism etc.Academic / school concerns — learning disabilities, special needs etc.Work-related stress / financial stressFaith-related / spiritual distressOther

How much have your emotional or mental health concerns affected your ability to function in daily life (e.g., work, school, home, relationships)? *

I am able to manage my daily responsibilities with minimal difficulty.I am having noticeable difficulty managing some areas of daily life.I am struggling significantly and unable to manage most daily responsibilities.

To help us serve you better, can you tell us more about the main reason you are seeking help today (in 50 words)? *

0 words · 10–50 words

Your answers help us get you the right level of care. They stay confidential.

Are you currently having thoughts of harming yourself? *

YesNo

Have you ever had thoughts of harming yourself in the past (less than 6 months ago)? *

YesNo

Do you feel safe right now? *

YesNo

Informed Consent

By proceeding, you agree to the following:

This is a brief mental health consultation (up to 30 minutes) and not ongoing therapy or a comprehensive psychological evaluation.
The purpose of this consultation is to better understand your concerns, provide recommendations, and discuss appropriate follow-up options.
Your information will be kept confidential and shared only as permitted by law and as necessary to provide your care, including care coordination, clinical supervision, and consultation with members of the care team.
Information may be disclosed without your consent if required by law or if there is concern for your safety or the safety of others.
Participation is voluntary, and you may stop the consultation at any time.

Your permissions

Treatment Consent*I consent to receive mental health consultation services.Use & Disclosure of Information*I consent to the use and sharing of my information for treatment, care coordination, clinical supervision, and operational purposes.Research & Quality ImprovementI consent to the use of my de-identified information for research and quality improvement purposes.

I confirm that I am the patient's parent or legal guardian and have the authority to provide consent on their behalf.

You can change any of these at any time from your profile page after sign-in. Required permissions are needed for the platform to deliver care.

After you submit, you’ll see a confirmation screen. Our care team will review your information and notify you on Mahal Us Shifa with the next step.

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