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Initial Consultation Registration Form
REGISTRATION FORM | ALL INFORMATION IS STRICTLY KEPT CONFIDENTIAL
15
Questions
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1
May we have your full name, please?
*
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First Name
Last Name
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2
What is your preferred name that we can address you with?
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3
May we have your contact details?
*
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Please enter your email address here.
Please enter your contact number along with area code
Please enter your full home address.
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4
How about your date of birth?
*
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-
Date
Day
Month
Year
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5
May we know your marital status?
*
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Married/Divorced/Partnered/Single/Widowed
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6
Whom should we contact in case of emergencies?
*
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Emergency Contact: Name | Relationship | Contact Number
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7
When was your last medical check-up?
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Doctors' Names | Address | Date of Last Check-Up
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8
Please disclose any pre-existing medical conditions that you may have.
*
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Health Issues | Medications Taken
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9
Briefly describe any childhood issues you have experienced.
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10
What is the main reason for this consult?
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Please give a brief background of your current concern, how long has it been going on and what have been done about it?
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11
From the list below, please indicate the areas that concern you.
*
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Achieving Goals
Addictions
Anxiety
Career
Cancer
Childhood Problems
Concentration
Confidence
Compulsive Behaviour
Dementia
Depression
Diabetes
Drinking
Drugs
Exam Stress
Eating Disorders
Fears
Fertility
Food Issues
Gambling
High Blood Pressure
High Cholesterol
High Blood Sugar
Motivation
Memory
Pain Control
Panic
Phobias
Public Speaking
Medical Issues
Self-Esteem
Sexual Problems
Sleep Problems
Skin Complaints
Smoking
Stress
Stroke
Relationships
Weight Issues
Other
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12
What is the ideal outcome you would like to get out of this session?
*
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Be as specific as possible. How would you assess if the session has been impactful for you? What would be the before and after difference that you are striving for?
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13
Declaration
*
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By signing the intake form, I have read and agree to the terms of service. The information I have given here is to the best of my knowledge, full and correct. I undertake therapy on the understanding that it is a collaborative process, and that progress depends in part on my own motivation and participation. I also accept that all appointments not cancelled within 48 hours will be charged in full.
Clear
Signature and Date
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14
Would you like to confirm your session?
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ORDER SUMMARY
Total cost
SGD
Initial Consultation
Includes a Six Seconds Emotional Intelligence Report
$
180.00
SGD
+
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15
Pay with PayPal
Debit Or Credit Card
Select PayPal Method
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
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the form.
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