Counselling Registration Form

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

Please fill up all the information in the form below.

By filling up this form you agree consent to receive face-to-face / web-based counselling and the recording of session for safety purposes. Recordings will be stored and kept securely under PDPA guidelines.

Counselling is a confidential process which involves sharing of sensitive concerns and issues that may reveal personal and private information. The contents or the information disclosed will be kept strictly confidential under normal circumstances except for the two clause stated below:

EXCEPTIONS TO CONFIDENTIALITY:

Suggestion / intention / evidence of suicide threats, suicide ideation, harm to self or others. Under this clause the counsellor will NOT BE BOUND by the confidentiality clause,

Suggestion / intention / evidence of physical, emotional or sexual abuse or legal violation the counsellor will NOT BE BOUND by the confidentiality clause,

As professionals are legally bound by the law of Singapore to report at-risk behaviour to the relevant authorities to ensure safety for the client and others who may directly or indirectly be affected.

Salutation *

First Name *

Last Name (Surname)

Age *

NRIC/FIN/BB/PP (last 3 numbers + alphabet) *

Ethnicity *

Religion *

Country of origin *

Nationality *

Languages Spoken *

Occupation *

Education Level *

Contact Number *

Email *

Gender *

Marital Status *

Emergency Contact Number *

Emergency Contact Person *

Relationship to Client

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Appletree Counselling. Report Abuse

Forms