Further details | Mental Health Counselling

Details required prior to consultation

Full name *

Age *

Gender

Man

Woman

Referring clinician / Hospital name *

Phone number *

E-mail ID *

State / City / District *

Referral reason

Have you taken any previous consultation at Lilac

Yes

When did you take the previous consultation at Lilac *

Have you done any tests with Lilac Insights?

Yes

Patient name for previous test done at lilac *

Test name for previous test done at lilac *

Sample id for previous test done at lilac (as per report) *

Is this your first consultation with lilac

First

Follow-up

Choose an appropriate option:

Obstetric/ Prenatal

Paediatric

Adult

Referring clinicians notes/ prescriptions/ other clinical evaluation reports

Attached document

USG scan reports (Eg for 9th, 12th, 16th or 19th weeks' scan reports)

Attached document

Screening report Eg. double marker, quadruple, triple, NIPS etc.

Attached document

Blood test reports of the mother- Eg. CBC, thyroid, blood glucose, HPLC, TORCH, antibody testing, APA thrombophilia’s and other blood test if any.

Attached document

Previous genetic test report if any; Eg. Karyotype, Microarray, CES or any other genetic test report.

Attached document

USG brain, MRI, EEG, CT scan, X-rays, BERA/Audiometry etc.

Attached document

Development evaluation

Attached document

Previous genetic test report; Karyotype, Microarray, CES or any other genetic test report.

Attached document

If case of neonatal death- death summary, images of the child

Attached document

Blood tests, any biopsy results, semen/sperm analysis. Any USG/ xrays/ MRI etc

Attached document

Previous genetic test report; Karyotype, Microarray, CES or any other genetic test report

Attached document

Previous appointment summary report

Attached document

All the test reports of recommended tests during previous session

Attached document

Client intake form - Platform

PART A - Demographics (to be filled by patient)

To be filled by both partners

SELF

1. Full name *

2. Date of birth *

3. Blood group *

4. Address *

5. Telephone no. *

6. E-mail ID *

7. Occupation *

8. Nationality *

PARTNER

1. Full name *

2. Date of birth *

3. Blood group *

4. Address

5. Telephone no.

6. E-mail ID *

7. Occupation *

8. Nationality *

1. Referring doctor name *

2. Referring doctor center *

3. Referring doctor contact number (optional)

PART B - Clinical history (to be filled by patient)

1. Are you married consanguineously (within blood relatives)?

Yes

2. Is there an ongoing pregnancy?

Yes

The gender of the fetus will not be disclosed in accordance with the PCPNDT act and I will not discuss the gender of the fetus for non clinical purposes.

3. LMP Date *

Are you sure?*

Yes

4. Menstrual Cycles?

Regular

Irregular

5. Conception Type?

Natural

Ovulation drugs

IUI

ICSI

IVF self gametes

IVF donor gametes

IVF donor embryo

Surrogate

6. Height of birthing individual (pregnant lady) (cms/ft)

cms

inch

cms

7. Weight of birthing individual (pregnant lady) (kgs)

8. Smoking?

Yes

9. Alcohol?

Yes

10. Is the birthing individual (pregnant lady) on any medication?

11. Any health problems of the birthing individual (pregnant lady) ?

PART C - Advanced clinical history (to be filled in by Trainee GC)

1. Obstetric History:

a. How many pregnancies so far -

None

b. Living children

Before 37 weeks

After 37 weeks

Type of delivery

Normal

LSCS

c. Neonatal death

Before 37 weeks

After 37 weeks

Type of delivery

Normal

LSCS

d. Miscarriage / IUD

< 15 weeks

16 - 27 weeks

28 - 36 weeks

> 37 weeks

16 - 27 weeks

f. Ectopic pregnancies?

2. Any complications in the previous pregnancy(ies)?

3. Medical history:

a. Diabetes

Yes

a. High blood pressure

Yes

a. Kidney problem

Yes

a. Breathing problem

Yes

a. Stomach problems

Yes

a. Liver problems

Yes

a. Epilepsy

Yes

a. Infections

Yes

a. Autoimmune conditions

Yes

4. If yes for above, please list medications?

5. Any family history of birth defects?

Yes

a. If yes, give details

PART D - Reports/ Investigations (to be filled by Trainee GC)

Please upload any relevant documents in PDF/JPG format.

Attached document

I hereby declare that all the information provided by me thus far is true and accurate.
I hereby authorize {{ vars.consultation.doctor.display_name }} to access the above shared information and case reports.
I allow lilac insights to anonymously use my clinical data for research purposes.

AtEase Informed Consent Form

By signing this Informed Consent Form, you hereby provide your consent for doing a video/ in-person consultation with AtEase (an inclusive mental health platform by Lilac Insights) Mental Health Consultation team.

Thank you for trusting AtEase. We are glad you have decided to take that first step in reaching out for support and we appreciate you giving us the opportunity to work with you. This website is intended to provide you with information about the therapist’s qualifications, treatment approach and services offered as well as to hopefully answer any other questions you have about what to expect and the nature of the therapeutic process.

Therapy information:
The type of therapy will be tailored towards the individual and unique needs of each client which will help us navigate through your difficulties.

The common therapy approaches our Experts are:

● Trauma-informed care
● Person-centered therapy
● Interpersonal therapy
● Cognitive behavioral therapy

Confidentiality:
Protecting your privacy is very important to me. The information in your record is confidential and will not be disclosed to anyone without your written consent, unless required by law. The exceptions to confidentiality include:
If you tell us that you are going to harm or kill yourself or someone else, we are required by law to do whatever we can do to prevent that from happening and to ensure your safety and the safety of others. This may require notifying family members, parents, legal guardians, legal authorities and/or the potential victim.

We are required to release your records if they are subpoenaed by a court of law In addition to the above, there are several other situations where confidentiality cannot be insured, including:

● If you provide us with the request to release your records
● If you are a child (under 18 years of age) or unable to voluntarily consent, a guardian must give written consent and can access you records.

Apart from the AtEase expert you will be working with, our AtEase team may have access only to your name and contact details (i.e., mobile number and email ID) to assist you when you are facing technical difficulties and/or to reach out to you for follow-up sessions. The AtEase team (besides Experts) will not have access to other details such as the information mentioned in your intake form, session notes, or any other document that contains your personal information.

Cancellation Policy:
If you don’t attend the session you have booked without notifying us the full fee will be charged In order to help as many families as possible we ask you to adhere to these cancellation policies. We appreciate your understanding in this matter

● If you are unable to keep you scheduled appointment time, please provide us as much notice as possible. Psychologists do not double book appointments, so the appointment you have made is exclusively for you
● We need at least a 24 hour notice to attempt to fill the appointment time should you cancel or reschedule. SO, we ask that you consider this when changing or cancelling a scheduled appointment

I have read and fully understood the Terms and Conditions. I agree to the policies and procedures explained in this Informed Consent Form. I agree to accept Services from AtEase (Lilac Insights) and am voluntarily giving consent.

Type Your Name *

Client intake form

Personal Information

Full Name *

Phone Number *

Emergency Contact *

Current Location (City) *

Referred by

Date of Birth *

Age *

Gender Identity

Man

Woman

Non-Binary

Transgender

Gender Fluid

Other

Your pronouns

She / Her

He / Him

They / Them

He / They

She / They

Other

Sexual orientation

Heterosexual

Lesbian

Gay

Bisexual

Queer

Asexual

Other

Relationship Status

Single

Married

Domestic Partnership

Divorced

Widowed

Are you currently employed?

Select

Yes

Are you a home maker?

Select

Yes

Reproductive History(please tick any one): *

Select

Client History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *

Select

Yes

Are you currently taking any psychiatric medication? *

Select

Yes

Is there a history of mental illness in the family? *

Select

Yes

Information on mental & physical health

How would you rate your current physical health? *

Select

Poor

Unsatisfactory

Satisfactory

Good

Very good

How would you rate your current sleeping habits? *

Select

Poor

Unsatisfactory

Satisfactory

Good

Very good

How would you rate your current eating habits? *

Select

Poor

Unsatisfactory

Satisfactory

Good

Very good

Are you currently experiencing overwhelming sadness, grief or depression? *

Select

Yes

If yes, for approximately how long? *

Are you currently experiencing anxiety, panics attacks or have any phobias? *

Select

Yes

If yes, when did you begin experiencing this? *

Do you drink alcohol more than once a week? *

Select

Yes

How often do you engage in recreational drug use? *

Select

Daily

Weekly

Monthly

Infrequently

Never

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

What are your expectations from therapy? *