COMEBACK Registration Form

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Please fill up this form so that our psychologists and team will have basic information about the gamer registering for personal consultation and/or COMEBACK Program. All the information required below are the gamer's unless otherwise stated.

The charges for consultation with COMEBACK Psychologists are as follow:
Associate Psychologist: $200/hr (office hours) & $230/hr (after office hours)
Principal Psychologist: $250/hr (office hours) & $330/hr (after office hours)
Note: 15min past the hour additional $50 (associate)/ $60 (chief). 30min past the hour additional $100 (associate)/ $120 (principal). After 30 minutes into the hour, the full hour rate is charged.

Email *

First Name *

Last Name *

Gender *

Male

Female

Race/Ethnicity *

Chinese

Malay

Indian

Other:

Date of Birth *

YYYY

Nationality *

Residential Address, including Postal Code *

Current School/Workplace *

Current School Level/ Work Designation *

Reasons for COMEBACK Services *

Please give us a brief description of the key challenges you are facing.

Existing physical and psychological conditions *

Currently seeing a psychiatrist, psychologist or counsellor? *

Yes

Current medications if any *

Email Contact (Parent/Guardian's if gamer is below 21 years old) *

Mobile Phone Contact (Parent/Guardian's if gamer is below 21 years old) *

Name of Parent/Guardian if gamer is below 21 years old *

I agree to providing my and/or my child's personal data to COMEBACK PTE LTD for its services (Please read details) *

I hereby authorise, agree and consent to allow COMEBACK PTE LTD to collect, use, disclose and/or process my personal data that I now provide for the following purposes:- facilitating, processing, dealing with, administering, managing and/or maintaining our relationship with COMEBACK PTE LTD;- dealing in any matters relating to COMEBACK PTE LTD products, services and activities;- carrying out due diligence and other screening activities, or to prevent or investigate any fraud or breach of contract or unlawful activity, or complying with or as required by any applicable law, governmental or regulatory requirements of any relevant jurisdiction;- conducting research, analysis and development activities (including but not limited to data analytics, surveys and/or profiling) to enhance COMEBACK PTE LTD products, services and/or operations, and/or otherwise for COMEBACK PTE LTD’s business operations and purposes;- storing, hosting, backing up (whether for disaster recovery or otherwise) of my personal data, whether within or outside Singapore,- disclose personal data about me to COMEBACK PTE LTD’s third party service providers and agents (“Representatives”) that are engaged by COMEBACK PTE LTD to perform certain functions in connection with the Purposes, so long as disclosure is necessary to enable such Representatives to perform the said functions. The Representatives may be located within or outside Singapore. In this regard, I hereby acknowledge, agree and consent that the said Representatives may, to the extent necessary to perform the said functions, collect, use, disclose and/or process my personal data. (collectively the “Purposes”);Should you wish to withdraw your consent in part or whole, please send an email to hi@comeback.world and provide details of your withdrawal. If you have any questions relating to our collection, use and disclosure of your personal data or the matters set out here, you may contact us.

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