Full Name

Phone Number

Who is this treatment for? Please SelectMyselfA Family MemberA Friend

Primary concern you're seeking help for? Please SelectAlcohol AddictionDrug AddictionDepression/AnxietyStress or TraumaOther Mental Health IssueNot Sure

What expectations do you have from the treatment? Private room with full-time care and personal attentionComfortable stay with 24/7 medical and therapy supportDay care facility (patient comes during the day only)Full recovery program including detox and counselingYoga, meditation, and therapy -based healingI'm not sure yet - need guidance

What is your monthly budget for treatment? Please Select(20,000 - 30,000)INR(30,000 - 50,000)INR(50,000 - 1,00,000)INR(Above 1,00,000)INR

How soon would you like to schedule a visit or appointment?

Please explain your concern