新冠肺炎社会心理支持援助计划开放申请 COVID-19 Psychosocial Support Assistance Programme Open for Application

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对象：受冠病疫情影响的家庭【本身或家人确诊】
Target Population: Family affected by COVID-19 [Self or family member diagnosed with COVID-19]

目标 Objective：提供社会心理支持及关爱予受影响的家庭 Provide psychosocial support and care to the family affected by COVID-19

服务：线下家访、线上活动、线上心理咨询/心理支援小组
Services: home visit, online activity, online counseling/support group

*** 每个家庭只限一人申请。 Limited to only ONE (1) application per family

Email *

姓名 (英）Name (English) *

姓名 (中）Name (Chinese)

联络号码 Contact Number *

州属 State *

玻璃市 Perlis

吉打 Kedah

槟城 Penang

霹雳 Perak

雪隆 KL/Selangor

森美兰 Negeri Sembilan

马六甲 Malacca

柔佛 Johor

登嘉楼 Terengganu

吉兰丹 Kelantan

彭亨 Pahang

沙巴 Sabah

砂劳越 Sarawak

居住地址 Residential Address *

家庭成员人数 No of Family Members *

受冠病影响 / Affected by Covid-19 *

* 请打勾：受影响方面。*Example: Please tick: Affected aspects

家人或本身因冠病而影响生计或失去工作能力 Family members are affected by the Covid-19 or lose their ability to work

家人或本身因冠病而失去体制内学习机会 Family members have lost the opportunity to learn within the system due to Covid-19

家人或本身因冠病而影响对外人际关系 Family members' external interpersonal relations are affected by Covid-19

家人或本身因冠病而影响家人感情 Family members affected family relationships due to Covid-19

家人或本身因冠病而影响心理健康 The mental health of family members is affected by Covid-19

家人或本身曾受感染，康复但体弱 Family members have been infected and recovered but are frail

家人或本身曾受感染，现已康复 Family members have been infected and have recovered

家人曾受感染而逝世 Family members have been infected and passed away

Required

预期计划 Estimated Project Timeline

第一阶段Phase 1：家访 Home Visit（05/2022 - 07/2022)
第二阶段Phase 2 : 线上心理支援讲座 Online Psychosocial Support Talk
(a) 哀伤与失落 Grief and Loss (08/2022)
(b) 压力管理 Stress Management (08/2022)
**第三阶段 Phase 3: 线上心理辅导咨询/支援小组 Online Counselling/Support group (08/2022 -11/2022)
**Optional 可选择是否参与

本人在此证实已阅读注意事项，并同意配合此计划的安排。I hereby acknowledge that I have read through the matters to take note and agree to cooperate fully with the arrangements of project. *

Agree 同意

Disagree 不同意

录取的家庭务必参与此计划的安排，包括：线下家访、线上心理支援讲座与问卷回馈 The families enrolled must participate in the arrangements of this project, including home visits, online psychosocial support talks and feedback via questionnaire. *

Agree 同意

Disagree 不同意

此计划只限100户家庭，符合资格的家庭将收到电话通知。 This project is limited to only 100 families and eligible families will be notified by phone.

A copy of your responses will be emailed to the address you provided.

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