Client Intake, ACEs & Consent Form

If you are struggling with suicidal/self-harm thoughts or experiencing mental health crisis that require urgent help, please contact the following helplines or go to the nearest hospital or the 24-hour Emergency Services of the Institute of Mental Health.

IMH Mental Health Helpline: 6389 2222

Samaritans of Singapore 24-hour Hotline: 1800-221 4444

Client's Name*

First NameLast Name

He/HimShe/HerOthers

Date of Birth

Date

Address

Contact number*

Email address*

EmployedNot employed

Occupation (if any)

Referred by (if any)

Name of Emergency Contact*

Relationship to you

Contact Number*

NoYes

If yes, please elaborate on your previous engagement of mental health services:

NoYes

If yes, please elaborate on your medications:

If yes, please state date of last incident:

PoorUnsatisfactorySatisfactoryVery good

Please list specific sleeping problems or sleep issues you are experiencing (if any):

Please share a brief description of your situation:

What would you like to accomplish out of your time with us? (Goals)

Signature*

Date

Client Information

Emergency contact

History

Mental Health Information

Personal Data Protection Act (PDPA) compliance:

Adverse Childhood Experience (ACE) Questionnaire