Support Group Registration
You have shown interests in joining support groups, please provide further information to help me organise it.
Email address *
What's your name? *
Your answer
What's your gender? *
What's your date of birth? *
MM
/
DD
/
YYYY
What is your contact numbers? *
Your answer
Where are you based and where can you travel to? (Please select as many options as possible) *
Required
What language do you speak? *
Required
What support group would you like to join? *
Have you been diagnosed or assessed by a clinician (Dr, psychiatrist, clinical psychologist, counsellor etc) for the problem above? *
Are you currently undergoing any treatment (medication, counselling, psychotherapy etc)? *
What is your preferred timing for the support group meeting? *
Required
What do you expect of the frequency of meeting? *
Will you be able to arrange for your own transport to the meeting location? *
Will you be able to pay for your own spending/expenses? (e.g. We might meet in a cafe, will you be able to buy yourself drink/snack/meal?) *
Will you be willing to pay a small administration fee of RM10 or so for each meeting? *
Finally, what do you expect from the support groups? Also, let me know if you have any other preference. *
Your answer
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