Details required prior to consultation

Client intake form - Platform

PART A - Demographics (to be filled by patient)

To be filled by both partners



PART B - Clinical history (to be filled by patient)

The gender of the fetus will not be disclosed in accordance with the PCPNDT act and I will not discuss the gender of the fetus for non clinical purposes.


PART C - Advanced clinical history (to be filled in by Trainee GC)

PART D - Reports/ Investigations (to be filled by Trainee GC)

I hereby declare that all the information provided by me thus far is true and accurate.
I hereby authorize {{ }} to access the above shared information and case reports.
I allow lilac insights to anonymously use my clinical data for research purposes.

AtEase Informed Consent Form

By signing this Informed Consent Form, you hereby provide your consent for doing a video/ in-person consultation with AtEase (an inclusive mental health platform by Lilac Insights) Mental Health Consultation team.

Thank you for trusting AtEase. We are glad you have decided to take that first step in reaching out for support and we appreciate you giving us the opportunity to work with you. This website is intended to provide you with information about the therapist’s qualifications, treatment approach and services offered as well as to hopefully answer any other questions you have about what to expect and the nature of the therapeutic process.

Therapy information:
The type of therapy will be tailored towards the individual and unique needs of each client which will help us navigate through your difficulties.

The common therapy approaches our Experts are:

Protecting your privacy is very important to me. The information in your record is confidential and will not be disclosed to anyone without your written consent, unless required by law. The exceptions to confidentiality include:
If you tell us that you are going to harm or kill yourself or someone else, we are required by law to do whatever we can do to prevent that from happening and to ensure your safety and the safety of others. This may require notifying family members, parents, legal guardians, legal authorities and/or the potential victim.

We are required to release your records if they are subpoenaed by a court of law In addition to the above, there are several other situations where confidentiality cannot be insured, including:

Apart from the AtEase expert you will be working with, our AtEase team may have access only to your name and contact details (i.e., mobile number and email ID) to assist you when you are facing technical difficulties and/or to reach out to you for follow-up sessions. The AtEase team (besides Experts) will not have access to other details such as the information mentioned in your intake form, session notes, or any other document that contains your personal information.

Cancellation Policy:
If you don’t attend the session you have booked without notifying us the full fee will be charged In order to help as many families as possible we ask you to adhere to these cancellation policies. We appreciate your understanding in this matter

Client intake form

Personal Information

Client History

Information on mental & physical health