Free Consultation – Lily Agarwal

Notice: This service is not equipped to provide crisis care. If you are in danger of harming yourself or being harmed by someone, please immediately contact a doctor, an ambulance, a hospital or the police.

Thank You…. for your decision to take the first step.

“As you start to walk on the way, the way appears.”

~Rumi

The information you share with me in this form will make it possible for me to understand where you are at, what you need and how best I can be of service to you.

First Name *

Last Name *

Emai *

Phone Number *

DOB *

Gender *

Relationship Status *

Address *

City *

Post Code *

Country *

Occupation *

What is the 1 main condition, you seek therapy for? *

What are the symptoms, triggers or habits the condition creates? *

What is the outcome you wish for? *

Are you under care of a doctor? *

If yes, please state diagnosis, prognosis and medications prescribed *

Doctor’s name, address & contact number *

Please select the areas that currently concern you from the list below: * Please tick atleast oneStressAnxietyDepressionPanic AttacksFearsPhobiasTraumaGuilt, Shame & BlameNervousnessAngerFrustrationGrief & LossBereavementNervousnessPre-natal SupportChildhood IssuesTooth & Gum Decay IssuesImprove EyesightImprove HearingPain-freeFertility & ConceptionPregnancy & BirthingRepeated MiscarriagesSkinHairInsomniaWeight LossWeight GainUlcersAsthmaHay FeverAllergiesChronic ConditionsLifestyle ConditionsCancer SupportSmokingAlcoholDrugsGamblingSexDigitalAnorexiaBulimiaTrichotillomaniaADD/ADHDOCDSelf-esteemSelf-confidenceSelf-loveProcrastinationLife PurposeLonelinessConnection & BelongingBody ImageSocial ConfidenceSleeping PatternsPunctualityPersonal RelationshipsProfessional RelationshipsFamily RelationshipsSleeping PatternsMarital RelationshipsSexual & IntimacySportsCareerBusinessMoney BlocksInterview SkillsPublic SpeakingExam ResultsAcademicMusicCreative writingCreative Blocks

Have you been diagnosed with a Psychotic condition? If yes, are you prescribed antipsychotic medications? *

Have you suffered Epileptic fits? If yes, provide a brief history of condition and medication *

How did you hear about Lily? If referred, please state name of the person/organization/professional. *

Initial Consultation:

Preferred date 1 *

Preferred date 2 *

Preferred time of day *

Please check out the Terms & Conditions & Disclaimer as listed on the website.

Thank you for taking the time, to share your information with me.
Your personal information remains private & confidential. It is securely stored, if you proceed with the therapy, if not this form will be deleted, disposed & destroyed safely & immediately.

Click on the button below to send the form to your RTT Therapist.

Response time: within 24 hrs.