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Mathew's St. John's Counselling Contact Form
If you do receive any response after submitting this form online within 2 days, please check your email junk folder or email to me at mathew.ho@sjccs.hk
Information provided are private and confidential.
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* Indicates required question
Email
*
Your email
Full Name (with Surname in CAPS)
*
Your answer
Gender (Identified)
*
Female
Male
Other:
Year of Birth
*
Your answer
Contact Phone
*
Your answer
What is your primary concern or issue you desire to explore in counselling / mediation? Have you sought professional help for this issue(s)?
*
Your answer
Have you experienced psychiatric/mental health problems? Have you sought professional / psychiatric services for it? Are you currently on any medication?
Your answer
Are you currently involved in any legal proceedings? If yes, a brief description please.
Your answer
Have you experienced any thoughts and/or attempts of harming yourself or others? If yes, a brief description please.
Your answer
What is your employment status and job field?
*
Your answer
Number of family members in your household (including yourself)?
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Your answer
What is your monthly FAMILY (not individual) income? (HK$)
*
Below $10,000
$10,001 - 20,000
$20,001 - 40,000
$40,001 - 60,000
$60,001 - 80,000
$80,001 - 100,000
Aove $100,000
What language do you prefer to use?
*
English
Cantonese
Other:
Services required (Fees per 50 minutes)
Individual Counselling: $1,000 - $1250
Couple or Family Counselling: $1,500 - $2000
Mediation : $1,250 initial session (subsequent sessions at a scaled fee schedule)
Other:
Additional Information
Your answer
What next?
Please make sure that you click the "SUBMIT" button at the bottom of this form.
After submitting, please wait for me to contact you via email.
If you do not receive any email from me, please check your junk or spam mail.
Then please contact me at mathew.ho@sjccs.hk so that I can follow up.
Send me a copy of my responses.
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