Registration Form - Online Psychotherapy

第一次的心理咨询 (90分钟): RM200
联络号码:+6011-33445270 [WhatsApp]

Our clinical psychologists at MY Psychology provide online psychotherapy services. To understand more about online psychotherapy, click the link here:

1st Session (90 minutes): RM200.
Contact Us: +6011-33445270 [WhatsApp]
Name / 名字 *
Your answer
Preferred device / 首选设备 *
以下哪一个设备适合你来进行线上心理治疗?Which of the following device that is suitable for you to have online psychotherapy session?
Email Address / 电邮 *
We will contact you via Email / 我们会透过Email联络你。
Your answer
Phone Number / 联络号码 *
We will contact you via whatsapp / 我们会透过Whatsapp联络你。
Your answer
Birth Date / 出生日期 *
IC / 身份证号码 *
Your answer
Home Address / 家里地址 *
Your answer
Gender / 性别 *
Occupation / 职业 *
Your answer
Preferred Language / 语言 *
Emergency Contact Name / 紧急联系人(名字) *
Your answer
Emergency Contact Number / 紧急联系人(联络号码) *
Your answer
Main reason to see a therapist / 咨询治疗师的主要原因 *
Your answer
Have you experienced any psychotherapy previously? / 请问你之前有接受过过心理治疗吗? *
Preferred Times for Online Appointment / 适合的线上心理治疗时间 *
Please suggest more than one time slot (eg: Mon: 9am to 12pm, Tue: 10am to 3pm). 请填写超过一个适和的诊疗时间 (星期一:900am to 12pm, 星期二:10am to 3pm)
Your answer
How did you hear about us? / 你是如何得知我们的? *
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