Mental Health Session Form

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Asha Tiwari

Psychologist

Specializations

Stress and conflict management
Work–life balance
Relationship and family dynamics
Women’s hormonal and emotional wellness

Bio

Asha is a psychologist specializing in women’s wellness, with expertise in stress management, conflict resolution, and emotional health. She supports women facing weight-related concerns, hormonal imbalances, PCOD/PCOS, and relationship challenges, helping them build resilience, balance, and emotional well-being.

Credentials

MSc in Clinical Psychology

Please read carefully. By checking the consent box you acknowledge and accept the terms below.

General Information

Counseling begins with an understanding of your background and concerns. We will collaboratively establish clear treatment goals, procedures, and a session schedule (time, place, duration) to ensure a tailored and transparent therapeutic process.

Responsibility for Adverse Events

Your mental health coach will provide professional recommendations, but outcomes can vary. You agree not to hold your mental health coach responsible for adverse events such as lack of improvement, deterioration, or situations posing a risk of harm to yourself or others.

Emergency / Crisis: If you are in crisis, seek immediate help from the nearest emergency department, a licensed mental health professional, or the helplines below:

TeleManas: 14416 or 18008914416 (24×7, Govt.)
iCall: 91529 87821 (Mon–Sat 10:00–20:00) • icall@tiss.edu

Confidentiality & Recording

All consultations are strictly confidential. Your mental health coach will not record audio/video sessions or share proceedings without explicit consent.
Exceptions: with your consent for supervision/training (identity protected); if legally mandated by a court; or when there is a clear and imminent danger to yourself or others (Duty to Warn). Session notes will be kept securely.

The contents of this form have been understood by me. After reading/listening to and understanding all of the above, I hereby give my consent for mental health sessions with psychologist in online mode. *Yes

Name *

Phone *

Email Address *

Do we have your permission to leave you a message or call you to schedule an appointment that may include Protected Health Information, such as your name, our name/practice, and reason for the call? *YesNo

Marital status: *SinglePartneredMarriedSeparatedDivorcedWidowed

How old you are? *

Have you taken any mental health services in the past? *YesNo

Do you have any family history of psychological illness? *YesNo

If yes, please indicate the family member/relationship affected: *

How would you describe your mental well-being at the present time? *Struggling a lotStruggling a littleManaging okayDoing wellThriving

Are you having any problems with your quality of sleep? *YesNo

If yes, check those that apply *Sleep too muchSleep too littlePoor qualityDisturbing dreamsOthers

Others *

Do you consume alcohol/substances regularly? *YesNo

In the last year, have you experienced any major life changes (employment, relocation, relationship, illness, loss of loved one, etc.)? *

Check off the issues that you might be struggling with: *Difficulty with relationshipsMood swingsTrouble planningLack of focusConfusionAnger issuesIndecisionWorryingOther

Mention here *

Someone You Can Trust

Please share the details of someone you trust, who can be contacted or informed by your Mental Health Coach in case of an emergency.

Your information will remain completely confidential and will only be used if absolutely necessary.

Contact Name

Relationship

Phone

Is there anything else you would like to share?