Registration Form 登记表格
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Date of Registration
MM
/
DD
/
YYYY
Full Name 姓名 (as per IC) *
Age 年龄 *
Gender 性别 *
IC number 身份证号码 *
Phone number 电话号码 *
Email Address 电邮地址 *
Address 地址 *
Preferred language 语言 *
Marital status 婚姻状态 *
Education (highest level of education completed) 最高学历 *
Occupation 职业 *
Diagnosis / medical conditions (if related) 健康状况
Please describe the main reason to see a therapist 请描述您咨询治疗师的主要原因 *
Have you experienced any psychotherapy previously? 请问您之前有接受过心理治疗吗? *
Emergency contact person 紧急联络人姓名 *
Emergency contact number 紧急联络人号码 *
Relationship with emergency contact person与紧急联络人的关系 *
Method of Therapy 治疗选项 *
Preferred Times for Appointment (e.g. Tue 10 am - 1 pm), Sun (4 pm - 7 pm) 适合的诊疗时间 (例如:星期二,早上10时至中午一时,星期日下午4时至7时) *
Please suggest more than 1 time slot. 请填写超过一个合适的诊疗时间
How do you know about us? 您是如何得知我们的? *
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