Bangkok Counselling Service: Appointment Request Form

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Open: Mon-Fri, 11:00 am - 7:00 pm., Sat 10:00 am. - 5:00 pm.
Close: Sun and Public Holidays

Contact us:
Email: info@BangkokCounsellingService.com
Website: www.BangkokCounsellingService.com
Tel Office: 02 286 1352
Mob: 094 084 3441 Eng
Mob: 094 084 3442 Thai

Our Service: https://www.bangkokcounsellingservice.com/services/
FAQ: https://www.bangkokcounsellingservice.com/therapy/frequently-asked-questions/

Name *

Pronoun

Gender *

Age *

Tel. *

Email (Please check if your email is correct, as we will only offer appointments via email) *

Where are you currently live such as Bangkok, perimeter, or other provinces? *

I would like an appointment for... *

Individual Counselling (in-person appointment)

Individual Counselling (Online appointment)

Couple Counselling (it only available for an in-person appointment)

Family Counselling (it only available for an in-person appointment)

Young person 11-18 years old

Perinatal-Infant Mental Health

For couples counselling, please put your partner's name and their email below.

I would like an appointment in... *

English

Thai

Availability *

Daytime - Monday to Friday appointments that start before 5.30pm

Evening - Monday to Friday appointments that start at 5.30pm or later

Saturday - appointments on Saturdays

The next available appointment

I’m “not” available on the following day.....

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What issues would you like to work on counselling? Please tick list below. *

Relationships

Perinatal-Infant Mental Health

Identity and Sexuality

Sex and Sexual Problems

Overthinking and Anxiety

Low Mood eg. Depression

Mood Regulation / Managing Feeling

Grief, Loss and Bereavement

Abuse / Neglect

Trauma

Issues with Food

Health and Wellness Issues

Something else

I'd rather not say

Don't know

Other:

Required

Have you had counselling before? *

Yes, just one appointment or assessment

Yes, less than 6 appointments

Yes, more than 6 appointments

Yes, more than 12 appointments

Other request

Once you send this form we will reply within 48hrs. If sent on Saturday, Sunday or public holidays we will reply on the next working day. If you do not see a reply, please check your junk or spam folders. *

Acknowledge

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