Psychologist Enrollment Form

Dear Respondent,

Please fill in the details below. You will be enrolled on the platform as a mental health provider. You can access your profile through a mail that you will receive once enrolled in the platform. You can edit the profile further according to your area of expertise.

Name (With suitable Prefix) *

First

Last

Email *

Contact No *

range Charges Your

Name of Your Practice (If Applicable)

Your Website URL (If Applicable)

City *

Pincode *

Birthdate *

Population Treated *

• Children
• Youth
• Adults
• Seniors
• Special Needs
• Specific Challenges
• Couples

Languages Preferred *

About Yourself *

Years of Experience *

Specialities *

Educational Qualification *

License No (If applicable)

Charges Online (Mention the range of charges) *

Charges Offline (Mention the range of charges) *

Aadhar Card/ Any other Identity Proof

Click or drag files to this area to upload. You can upload up to 3 files.

Submit