Qlinniq

I am registering for myself

ITS ID*

First name*

Last name*

Date of birth*

Gender*

City*

Country*

Email address*

Phone number*

WhatsApp number*

Same as phone

Password *

Confirm Password *

What brings you in today? * (select up to 3)

0/3 selected

Anxiety / excessive worryLow mood / depressionStress / feeling overwhelmedRelationship / marital concernsFamily conflict / parenting concernsGrief / lossTrauma / past experiencesAnger / irritabilityDevelopmental / behavioral concerns of childhood or adolescents — ADHD, autism etc.Academic / school concerns — learning disabilities, special needs etc.Work-related stress / financial stressFaith-related / spiritual distressOther

How much have your emotional or mental health concerns affected your ability to function in daily life (e.g., work, school, home, relationships)? *

I am able to manage my daily responsibilities with minimal difficulty.I am having noticeable difficulty managing some areas of daily life.I am struggling significantly and unable to manage most daily responsibilities.

Your answers help us get you the right level of care. They stay confidential.

Are you currently having thoughts of harming yourself? *

YesNo

Have you ever had thoughts of harming yourself in the past (less than 6 months ago)? *

YesNo

Do you feel safe right now? *

YesNo

Informed Consent

By proceeding, you agree to the following:

This is a brief mental health consultation (up to 30 minutes) and not ongoing therapy or a full evaluation.
Your information will be used only to understand your concerns and connect you with an appropriate clinician.
Your privacy is important to us. Your information will be kept confidential and shared only with the care team directly involved in your care, except if there are safety concerns (risk of harm to self or others).
You may choose to stop at any time.

For Minors

A parent or legal guardian must provide consent and be present at the time of the appointment for anyone under 18.

Your permissions

Treatment consent*Authorizes the care team to deliver mental health services to you, including assessments, sessions, and care planning.Data-use consent*Allows your protected health information to be used by the care team for continuity of care, scheduling, and clinical handoffs.Cross-border data transfer*Acknowledges that some application infrastructure (notifications, error monitoring) may process data outside India until full localization is complete.Optional outreachAllows the clinic to contact you about programs, surveys, or updates that aren't directly tied to your care.

I confirm I am the legal guardian and have the authority to consent on behalf of this patient.

You can change any of these at any time from your profile page after sign-in. Required permissions are needed for the platform to deliver care.

After you submit, you’ll see a confirmation screen. Our care team will review your information and notify you on Qlinniq with the next step.

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