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Online Therapy Registration Form
Take the first step towards better mental health
Personal Information
Full Name
Gender
Male
Female
Date of Birth
Age
Phone Number (WhatsApp preferred)
Email Address
Country of Residence
Emergency Contact
Optional but Recommended
Name
Relationship
Phone Number
Therapy Needs
What brings you to therapy? (Check all that apply)
Stress / Anxiety
Depression / Low Mood
Relationship / Marriage Concerns
Trauma / Grief
Family or Parenting Issues
Career / Life Balance
Other
Have you attended therapy before?
Yes
No
Are you currently on medication?
Yes
No
If yes, please specify
Session Preferences
Preferred Session Type
Individual
Couple
Family
Preferred Mode
Video Call
Audio Call
Chat/Text Therapy
Preferred Platform
Zoom
Google Meet
WhatsApp
Other
Preferred Therapist Gender
Male
Female
No Preference
Preferred Days & Times
e.g., Mondays and Wednesdays after 5 PM
Payment (in Naira ₦)
Session Plan
Single Session
₦15,000
4 Sessions
₦50,000
8 Sessions
₦90,000
Payment Method
Bank Transfer
Card Payment
Mobile Money
Password
Include caps and special character
👁️
Confirm Password
Include caps and special character
👁️
Consent & Confidentiality
I understand that online therapy is supportive and not a replacement for medical or emergency care.
I acknowledge that sessions are confidential, except where disclosure is required by law (e.g., risk of harm to self or others).
I consent to participate in online therapy sessions and agree to the platform's Terms & Conditions and Privacy Policy.
Submit Registration