Consult session for Multimodal Therapy

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form aims to find out more about your mental and emotional needs before contacting you for a complimentary consultation. The information will help us to assess your suitability for our therapy programmes, and to be referred for alternative supports.

Please note that this complimentary session is offered on a needs basis. It is not a therapy session, but an opportunity to understand more about arts based therapies for emotional healing. Kindly fill in this form if you are genuinely seeking therapeutic support.

For research or interest based inquiries, please email admin@actingupsingapore.com. Thank you!

Please provide your email address and/or contact number *

My name is... (this will be kept confidential) *

My profession is... *

Healthcare Worker

Social Worker

Education

Customer Service

Bankers

Private Hire Drivers

Other:

This consult is for... *

Myself

My child

My parent(s)

Other:

Age range *

Adolescent

Young adult

Adult

Senior adult

Child

I am seeking... *

Arts based therapy support

More information for educational purposes

Mental health support but unsure if arts based therapies are suitable for me

To gain knowledge

To gain career insights

Other:

Please tick the statements that are relevant for you. This will remain confidential and for our therapist's reference only. *

I am diagnosed with a mental health condition

I suspect I may have a mental health condition, however I am not yet diagnosed

I am seeking support for emotional matters

I am seeking coping methods

I am seeking emotional expression through the arts

I would like emotional and mental health support, however I am unsure of my options

I would like to explore alternative forms of therapy other than verbal counselling

I am currently on medication for a mental health condition

I am currently seeing a mental health professional for support (e.g. psychologist, psychiatrist)

Other:

Required

When do you hope to begin therapy sessions? *

Would you prefer individual or group therapy? *

Individual

Small group

My family members are supportive of me seeking therapeutic support *

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Not applicable

I understand that the complimentary consult is not a therapy session, and there will be no follow-up unless therapy sessions are engaged *

Yes

Required

Please provide 3 preferred dates and times for the consult, starting 8 Nov2021. *

Please include me in Acting Up's mailing list to be updated on upcoming events, workshops and therapy sessions *

Yes

Any other information you'd like us to know?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of actingupsingapore.com. Report Abuse

Forms