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Your Name*

First Last

Your Mobile Number*

Your Email ID*

Your Taluk*

Your District*

Case 1 - Select the Issues which seem relatable to you*

I am unable to sleep

I am not feeling hungry

I am very much malnourished

I have physical illness

I am suffering from psychological issue

I am unable to focus on my wellness

I want to know more about spiritual health

I am addicted to alcohol/tobacco/cell phone/internet

None of the above

Case 2 - Select the Issues which seem relatable to you*

I have problems with my parents

I have problems with my granddaughter/grandson/grandfather/grandmother

I have problems with my boyfriend/girlfriend/wife/husband/partner

I have fought with my friends

I have trouble with a friend whom I met online

I have problems in communicating with people

None of the above

Case 3 - Select the Issues which seem relatable to you*

I need to know more about myself

My self-esteem is low and I want to build it

I have too many emotional issues

I have a disturbed thinking pattern

I lack skills to handle negative emotions

None of the above

Case 4 - Select the Issues which seem relatable to you*

I am injured and I want to know more about first aid

I need information on legal aspects

I need to have more information on cyber safety

I am undergoing gender based violence at workplace/college/home

I have suicidal ideations or I feel like committing suicide

None of the above

Case 5 - Select the Issues which seem relatable to you*

I need to have a goal in my life. Currently I do not know what to do

I need to improve my concentration

I need to improve my memory

I have exam anxiety

I am stressed about my education and career ahead

I need to manage my time better

I am being ragged or bullied by my superiors/colleagues/friends

None of the above

Case 6 - Select the Issues which seem relatable to you*

I need to know about gender roles

I am a victim of gender discrimination and I need help

I am going through gender based violence

I am undergoing gender based violence at workplace/college/home

Me/My child/my friend/my colleague is sexually abused

I have sexually transmitted disease

None of the above

Would you like to have a FREE, one-on-one consultation with one of our Yuva Samaalochaka?*

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