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Newleaf Counselling Service Contact Form
New Leaf Counselling Service
新葉輔導服務
Please refer to our website
http://www.newleafcounselling.org.uk/?lang=en
for details
欲了解詳情，請瀏覽我們的網站
http://www.newleafcounselling.org.uk/?lang=zh
Please fill in the form if you would like to be contacted to have an assessment/counselling sessions
請填寫以下表格，讓我們接觸您進行輔導前評估
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* Indicates required question
Surname 姓
*
Your answer
First Name 名
*
Your answer
Age 年齡 (years old 歲數）
*
16-17
18-25
26-35
36-45
46-55
56-65
>65
Tel No 電話號碼
*
Your answer
Email Address 電郵
Your answer
Preferred Language 首選語言
*
Your answer
Second Preferred Language 次選語言
Your answer
Please tick the following which you would prefer to be contacted 請勾選以下聯絡途徑
*
Email 電子郵件
WhatsApp Message/SMS 短信
Phone 電話
Required
Please tick the following which you think is the most appropriate to your issues 請勾選您認為最適合您的問題的以下內容
Depression 抑鬱
Anxiety 焦慮
Bereavement 喪親
Substance Addiction 藥物成癮
Relationship Problems 關係問題
Other 其它
If you wish to, use the space below to describe your issues and expectations 若您願意，請使用下面的空格來描述您的問題和期望
Your answer
N.B. We are unable to provide any of the following: treatment for severe mental health illness, medical/medication advice or legal advice 請注意：我們無法提供法律諮詢；精神病例的治療；醫療或醫藥諮詢
Privacy protection statement: the information you submit is for assessment purposes only 隱私權保護聲明：你所遞交的資料只供輔導員作評估用途
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