count on me registration - Little Umbrella Foundation

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Complete your registration

Name *

First

Last

Phone

Email *

Date of Birth *//

Gender *

Male
Female
Others

Current Location *

Marital Status *

Married
Single
Divorced
Widowed
Seperated

How many hours do you sleep? *

0-3
3-6
6-9
9+

How strongly do you sleep?

Selected Value: 10

Where 0 being weakest and 10 being the strongest

Do you find daily activities challanging? *

Very less
Moderately
Very challaging
No Problem at all

How often do you experience the following moods?

Calm & Peaceful *

Never
Once in a while
Sometimes
Most of the times
Always

Energetic *

Never
Once in a while
Sometimes
Most of the times
Always

Gloomy *

Never
Once in a while
Sometimes
Most of the times
Always

Angry *

Never
Once in a while
Sometimes
Most of the times
Always

Do you have any dependencies?

Alcohol *

Socially
Frequently
Occasionally
Once in a while
I don't consume

Smoking *

Socially
Frequently
Occasionally
Once in a while
I don't consume

Do you have any compulsions/cravings other than the ones mentioned above? *

Are you currently taking any medications? *

Yes
No

Name of medicine *

Is this your first time in a Mental health support group? *

Yes
No
Do not wish to specify

Have you visited a professional therapist in the recent past? *

Yes
No

How did you hear about "Count on Me"? *

Social Media
Family or Friends
Through a psychologist
Corporate/ Educational Institute
Others

How did you hear about "Count on Me"? *

Accessibility
Subsidised Prices
Personal recommendation
Repeat Cutomer
Others

Single Line Text *

Count on me Terms and Conditions

Checkboxes *

I agree to the Terms and Conditions mentioned in the above link *

‘Count on Me’ Support Groups is a service provided by the ‘Little Umbrella Foundation'. Before you avail the services provided by 'Count on Me' Support Groups, please read the Terms and Conditions in the link below carefully and thoroughly. If you tick the box below, you will be deemed to have unconditionally agreed to the Terms and Conditions mentioned in the link below and they will govern your use of the services provided by 'Count on Me' Support Groups.