2020珍愛協談預約單 ( Family Counseling Center In-take Form)
1.預約協談類別 (Counseling Types): *
2.真實姓名 (Name) *
3.性別 (Gender) *
4.出生日期 (Date of Birth) *
MM
/
DD
/
YYYY
5.聯絡電話 (Contact number) *
6.E-mail *
7.職業 (Career) *
8.地址 (Address) *
9.婚姻狀況 (Marital status) *
10.緊急聯絡人 / 關係 / 電話 (Urgent contact/ relationship /number) *
11.如何得知珍愛協談中心? (Where did you learn of Family Counseling Center?) *
Required
12.曾經接受過其他輔導嗎? (Have you ever been in counseling before?) *
13.目前有服用精神科藥物嗎? (Are you taking psychiatric medications now?) *
14.欲談論主題 (The issues about which you would like to talk?) *
Required
15.您的問題的急迫性 (The urgency score varies from 1 to 5 ) *
to rate your problems
不緊急 (Least urgent)
非常緊急 (Most urgent)
16.近兩星期以來最困擾您的事? (What are the things that have been bothering you the most for the past two weeks?) *
17.您想預約的日期和時段(請填兩個時段)? (What date and time would you like to make an appointment with us? ) *
週一至週五 9:00-18:00 優先處理 (Our working hours. 09:00 am- 06:00 pm)
18.你相信上帝嗎? (Do you believe in God?) *
19.所屬教會 (The church you belong to ?) *
20.您期待得到什麼幫助? (What kinds of help would you like to get from our counseling? ) *
21.其他想問的問題 (Other questions?)
22.備註 (Remarks)
● 個人協談:1000元/每小時 (Personal counseling: 1,000 TWD/ per hour)

● 夫妻協談:1200元/每小時 (Counseling with couples: 1,000 TWD/ per hour)

● 家庭協談:1500元/每小時 (Counseling with the family:1,500 TWD/ per hour)
謝謝您耐心的填寫,珍愛家庭中心將會盡快與您連絡!(Thank you for your patience. We will get in contact with you as soon as possible!)
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