Online Registration for Services (CPCS)
Client Registration Form
Date (dd/mm/yyyy) *
Your answer
Where would you like to seek services from? *
*
Are you a returning client of CPCS? *
If "Yes", who is your previous therapist:
Your answer
Department (if applicable):
Your answer
Program of study:
Your answer
Student / Staff ID# (if applicable)
Your answer
Client's Name (as per I.C): *
Your answer
Contact Number: *
Your answer
Email Address: *
Your answer
NRIC / Passport #: *
Your answer
Date of Birth (dd/mm/yyyy): *
Your answer
Client's Age (according to actual birth date): *
Your answer
Gender:
Your answer
How did you find about our services?
Were you referred by someone? If yes:
Brief Statement of Issue (Not more than two lines): *
Your answer
Special Request (e.g: Language Preferred/Gender of Therapist): *
Your answer
Please list down days and times available for appointment (e.g. Mon 12 pm-5 pm) *
Your answer
PLEASE READ THIS INSTRUCTION BEFORE YOU PROCEED TO THE NEXT SECTION
*If you are 18 YEARS OLD & ABOVE, please continue the subsequent sections by following the instructions stated.

*If you are 17 YEARS OLD & BELOW (or) SIGNING UP FOR AN INDIVIDUAL WHO IS 17 YEARS OLD & BELOW, please continue the subsequent sections by choosing only response "O" or "NO" as the items are not applicable.
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