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Dear Participant

This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and national laws.

First Name

Middle Name

Last Name

Data of Birth

Address Line 1

Address Line 2

City

State / Region / Province

Postal / ZIP Code

Phone number

Email

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Are you currently employed?

Yes

No

Name of the employer

What kind of work do you do?

What kind of social activities do you participate in?

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Please describe any other symptoms or experiences you have had problems with:

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Consent *

I, having details as mentioned in the form, do declare as under:

I hereby declare my voluntary consent to participating in this programme at Chinta Mukti Margadarshan Kendra conducted by the Maitribodh Parivaar Charitable Trust (MBPCT).
I hereby declare that I am aware that this programme is no substitute for any therapeutic, medical or psychological treatment. I am at all times completely responsible for my own physical and mental health.
I declare that presently I am physically keeping good health and am emotionally capable of participating in this programme.
I hereby understand and acknowledge that after the initial screening, I may be advised to seek professional treatment with a certified Psychiatrist/Psychologist and that in case I choose not to follow the said advice, MBPCT reserves the right to restrict my further participation in this programme,
I agree to adhere strictly to the discipline of the programme and abide by the directions of the organizers or their nominees, at all times and shall not deviate from the same.
I voluntarily consent to receiving the sacred Maitri ShaktiPravaah, Maitri Light and other energy transfer processes organized by MBPCT as part of this programme.
I understand and agree that this programme is composed primarily of spiritual processes and activities and my successful completion of the programme will depend on my completion of the activities to the satisfaction of the organizers,
That I hereby hold harmless, indemnify, release and forever discharge MBPCT, its assigns and transferees from all claims, demands, and causes of action which I have or may have due to my participation in the programme.
I declare that my particulars given above are true and correct.

I agree to above terms and conditions.

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