{"id":2472,"date":"2021-05-25T22:36:42","date_gmt":"2021-05-25T17:06:42","guid":{"rendered":"https:\/\/nimh.health.gov.lk\/?page_id=2472"},"modified":"2021-05-25T22:38:09","modified_gmt":"2021-05-25T17:08:09","slug":"appointment-form-navodaya-patient-booking-system","status":"publish","type":"page","link":"https:\/\/nimh.health.gov.lk\/si\/appointment-form-navodaya-patient-booking-system\/","title":{"rendered":"Appointment Form &#8211; Navodaya Patient Booking System"},"content":{"rendered":"<h2>General Guidelines<\/h2>\n<h4>Read the following guidelines before filling the assesment form.<\/h4>\n<ul style=\"color: #555;\">\n<li>Navodaya is a Day Service providing psychological treatments &amp; specialized day services.<\/li>\n<li>Since clinical assessment has to be done, only general bookings can be accommodated via online.<\/li>\n<li>The service will not allow immediate bookings but with a <strong>3 working day gap<\/strong> (Saturday &amp; Sunday not included).<\/li>\n<li>This is only for booking and for <strong>emergencies<\/strong> to come to <strong>NIMH or nearest hospital<\/strong>.<\/li>\n<li>Followinf form has to be filled for all sessions even for repeat patients as mental states can change.<\/li>\n<li>The Navodaya team will assess the form and contact the patient and confirm your booking.<\/li>\n<\/ul>\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f2471-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/si\/wp-json\/wp\/v2\/pages\/2472#wpcf7-f2471-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2471\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2471-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:2471,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;medication-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;medication&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;mental_illness-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mental_illness&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;current_treatment-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;current_treatment&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;notice_dismissed_update-cf7-5.6.1&quot;:true}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<h3>Make an appointment today<\/h3>\n<div class=\"col-md-5\">\n<div>Mobile Phone Number:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap mobile-phone\"><input type=\"tel\" name=\"mobile-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Mobile Phone Number\" \/><\/span>\n <\/p><\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div>Gender<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gender\" value=\"Mx\" \/><span class=\"wpcf7-list-item-label\">Mx<\/span><\/label><\/span><\/span><\/span>\n <\/p><\/div>\n<div class=\"col-md-4\">\n<div>My general physical health is:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap physical_health\"><select name=\"physical_health\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Poor\">Poor<\/option><option value=\"Unsatisfactory\">Unsatisfactory<\/option><option value=\"Satisfactory\">Satisfactory<\/option><option value=\"Good\">Good<\/option><option value=\"Very Good\">Very Good<\/option><\/select><\/span>\n <\/p><\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>Are you currently on any medication:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap medication\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medication\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medication\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n <\/p><\/div>\n<\/div>\n<div data-id=\"medication-selected\" data-orig_data_id=\"medication-selected\"  data-class=\"wpcf7cf_group\">\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>If \u2018Yes\u2019 Please write your medication:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap medication_details\"><input type=\"text\" name=\"medication_details\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Write your medications\" \/><\/span>\n <\/p><\/div>\n<\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n  I\u2019m currently having the following issues (check all that apply)*\n <\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n  <span class=\"wpcf7-form-control-wrap issues\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Anxiety\" \/><span class=\"wpcf7-list-item-label\">Anxiety<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Appetite issues\" \/><span class=\"wpcf7-list-item-label\">Appetite issues<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Excessive crying\" \/><span class=\"wpcf7-list-item-label\">Excessive crying<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Depression\" \/><span class=\"wpcf7-list-item-label\">Depression<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Fatigue\" \/><span class=\"wpcf7-list-item-label\">Fatigue<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Excessive energy\" \/><span class=\"wpcf7-list-item-label\">Excessive energy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Compulsive behavior\" \/><span class=\"wpcf7-list-item-label\">Compulsive behavior<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Impulsive behaviour\" \/><span class=\"wpcf7-list-item-label\">Impulsive behaviour<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Irritability\" \/><span class=\"wpcf7-list-item-label\">Irritability<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Sleep changes\" \/><span class=\"wpcf7-list-item-label\">Sleep changes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Panic attacks\" \/><span class=\"wpcf7-list-item-label\">Panic attacks<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Hallucinations\" \/><span class=\"wpcf7-list-item-label\">Hallucinations<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Suicidal ideas\" \/><span class=\"wpcf7-list-item-label\">Suicidal ideas<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Phobia\" \/><span class=\"wpcf7-list-item-label\">Phobia<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"issues[]\" value=\"Suspiciousness\" \/><span class=\"wpcf7-list-item-label\">Suspiciousness<\/span><\/label><\/span><\/span><\/span>\n <\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n  Other: <span class=\"wpcf7-form-control-wrap issues_other\"><input type=\"text\" name=\"issues_other\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n <\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>Have you ever received psychotherapy or psychiatry treatment:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap psychotherapy\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"psychotherapy\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"psychotherapy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n <\/p><\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>Do you have a family history of mental illness:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap mental_illness\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mental_illness\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mental_illness\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n <\/p><\/div>\n<\/div>\n<div data-id=\"mental_illness-selected\" data-orig_data_id=\"mental_illness-selected\"  data-class=\"wpcf7cf_group\">\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>If \u2018Yes\u2019 Please give details:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap mental_illness_details\"><input type=\"text\" name=\"mental_illness_details\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n <\/p><\/div>\n<\/div>\n<\/div>\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>Are you currently under treatment for psychiatric illness:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap current_treatment\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"current_treatment\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"current_treatment\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n <\/p><\/div>\n<\/div>\n<div data-id=\"current_treatment-selected\" data-orig_data_id=\"current_treatment-selected\"  data-class=\"wpcf7cf_group\">\n<div class=\"row\">\n<div class=\"col-md-12\">\n<div>If \u2018Yes\u2019 Please give details:<\/div>\n<p>  <span class=\"wpcf7-form-control-wrap current_treatment_details\"><input type=\"text\" name=\"current_treatment_details\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n <\/p><\/div>\n<\/div>\n<\/div>\n<p><input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/><\/p>\n<p style=\"display: none !important;\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"208\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>General Guidelines Read the following guidelines before filling the assesment form. Navodaya is a Day Service providing psychological treatments &amp; specialized day services. Since clinical assessment has to be done, only general bookings can be accommodated via online. The service will not allow immediate bookings but with a 3 working day gap (Saturday &amp; Sunday [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"spay_email":""},"translation":{"provider":"WPGlobus","version":"2.10.2","language":"si","enabled_languages":["cl","en","si","ta"],"languages":{"cl":{"title":true,"content":true,"excerpt":false},"en":{"title":false,"content":false,"excerpt":false},"si":{"title":false,"content":false,"excerpt":false},"ta":{"title":false,"content":false,"excerpt":false}}},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v16.3 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Appointment Form - Navodaya Patient Booking System - \u0da2\u0dcf\u0dad\u0dd2\u0d9a \u0db8\u0dcf\u0db1\u0dc3\u0dd2\u0d9a \u0dc3\u0dde\u0d9b\u0dca\u200d\u0dba \u0d86\u0dba\u0dad\u0db1\u0dba, \u0dc1\u0dca\u200d\u0dbb\u0dd3 \u0dbd\u0d82\u0d9a\u0dcf\u0dc0<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/nimh.health.gov.lk\/appointment-form-navodaya-patient-booking-system\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Appointment Form - Navodaya Patient Booking System - \u0da2\u0dcf\u0dad\u0dd2\u0d9a \u0db8\u0dcf\u0db1\u0dc3\u0dd2\u0d9a \u0dc3\u0dde\u0d9b\u0dca\u200d\u0dba \u0d86\u0dba\u0dad\u0db1\u0dba, \u0dc1\u0dca\u200d\u0dbb\u0dd3 \u0dbd\u0d82\u0d9a\u0dcf\u0dc0\" \/>\n<meta property=\"og:url\" content=\"https:\/\/nimh.health.gov.lk\/appointment-form-navodaya-patient-booking-system\/\" \/>\n<meta property=\"og:site_name\" content=\"\u0da2\u0dcf\u0dad\u0dd2\u0d9a \u0db8\u0dcf\u0db1\u0dc3\u0dd2\u0d9a \u0dc3\u0dde\u0d9b\u0dca\u200d\u0dba \u0d86\u0dba\u0dad\u0db1\u0dba, \u0dc1\u0dca\u200d\u0dbb\u0dd3 \u0dbd\u0d82\u0d9a\u0dcf\u0dc0\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/NIMH.Angoda\/\" \/>\n<meta property=\"article:modified_time\" content=\"2021-05-25T17:08:09+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\">\n\t<meta name=\"twitter:data1\" content=\"1 minute\">\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebSite\",\"@id\":\"https:\/\/nimh.health.gov.lk\/#website\",\"url\":\"https:\/\/nimh.health.gov.lk\/\",\"name\":\"\\u0da2\\u0dcf\\u0dad\\u0dd2\\u0d9a \\u0db8\\u0dcf\\u0db1\\u0dc3\\u0dd2\\u0d9a \\u0dc3\\u0dde\\u0d9b\\u0dca\\u200d\\u0dba \\u0d86\\u0dba\\u0dad\\u0db1\\u0dba, \\u0dc1\\u0dca\\u200d\\u0dbb\\u0dd3 \\u0dbd\\u0d82\\u0d9a\\u0dcf\\u0dc0\",\"description\":\"\\u0dc1\\u0dca\\u200d\\u0dbb\\u0dd3 \\u0dbd\\u0d82\\u0d9a\\u0dcf\\u0dc0\\u0dda \\u0db8\\u0dcf\\u0db1\\u0dc3\\u0dd2\\u0d9a \\u0dc3\\u0dde\\u0d9b\\u0dca\\u200d\\u0dba \\u0db4\\u0dd2\\u0dc5\\u0dd2\\u0db6\\u0db3 \\u0dc0\\u0dd2\\u0dc1\\u0dcf\\u0dbd\\u0dad\\u0db8 \\u0dbb\\u0ddd\\u0dc4\\u0dbd\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":\"https:\/\/nimh.health.gov.lk\/?s={search_term_string}\",\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/nimh.health.gov.lk\/appointment-form-navodaya-patient-booking-system\/#webpage\",\"url\":\"https:\/\/nimh.health.gov.lk\/appointment-form-navodaya-patient-booking-system\/\",\"name\":\"Appointment Form - 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