Client Intake Form - Ms Adine
Thank you for your interest in speaking with trainee counsellor Ms Adine LOH. 

Please complete the form below, and your trainee counsellor will contact you shortly. 

This information is held to the same standards of confidentiality as our therapy sessions. 


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By submitting this Form, you hereby agree that Work Great on A Great Street may collect, obtain, store and process your personal data that you provide in this form for the purpose of counselling services. 

For the avoidance of doubt, Personal Data includes all data defined within the Personal Data Protection Act 2012, including all data you had disclosed to Work Great in this Form.


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Name (as per NRIC) *
Preferred Name *
Mobile Number *
Name of parent or guardian (if minor) *
Key 'NA' if not applicable
Last 4 digits of NRIC *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Preferred Pronouns *
Key 'NA' if no preferred pronoun
Nationality *
Marital Status *
Number of Children, and age of child *
Example: 2 children, ages 7 and 10 
Key "NA' if not applicable
Full Home Address (including postal code) *
Email Address *
Why are you seeking counselling? *
Please provide as much details as you can.
The section below contains 4 questions that will allow your trainee counsellor to better understand your current situation.  

Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services? 

 *
Have you had any mental health services in the past?  *
Are you currently taking any psychiatric prescription medication?  *
If you answered 'Yes' to the previous question, please list down your psychiatric prescription medication *
Key 'NA' if not applicable
Have you been prescribed psychiatric prescription medication in the past?  *
If you answered 'Yes' to the previous question, please list down your prescribed psychiatric prescription medication in the past *
Key 'NA' if not applicable
By checking this box, I declare that all information filled above is accurate *
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