Counselling Intake Form

Appointment Request

For new clients only
First Name*
Last Name*
Email Address*
Contact Number*
Sex*
Date of Birth*

DayMonthYear
Marital Status*
Year of Wedding*
Date of Wedding*

DayMonthYear
Please share about the issues or concerns you would like to seek help for:*
The information shared will help us in assigning a suitable Counsellor for you.
How long have you been experiencing this issue?*
Type of Session*

Face to FaceOnlineNo Preference
Clients Attending*

IndividualCoupleParent & ChildFamily (3 or 4)
How did you find out about us?*

Focus on the Family's Programmes & EventsGoogleFocus on the Family's WebsiteFacebookFocus on the Family's EmailInstagramOrganisations (e.g. Workplaces or Faith Communities)PodcastWord of MouthMedia MentionsOther
IMPORTANT - PLEASE READ THE FOLLOWING

Your privacy and trust in the counselling process is of paramount importance and crucial to its success.

Clients have the freedom of choice to enter into or remain in a counselling relationship, and the right to information about the counselling process. Counselling organisations have an obligation to clarify the counselling processes, rights and responsibilities of both counsellor and client.

Informed Consent is a process of communication between client and organisation. Its main purpose is to protect the client.

STATEMENT OF INFORMED CONSENT

Confidentiality

I understand that counselling-related information includes all forms of correspondence between client-organisation including session video recordings. In honouring client-counsellor privacy, all counselling-related information are kept confidential, with the following exceptions:

a) When the counsellor assesses foreseeable suicide risk in the client;

b) When the client acknowledges ongoing instances of incest, rape, abuse of a child, elderly, or disabled person;

c) When the client reveals his/her intention to commit a crime;

d) When the client can be accurately assessed as being a threat or danger to self, others or society;

e) When counselling information is subpoenaed by a court and/or relevant authorities

I understand that under such circumstances, my counsellor is bound ethically and legally to inform the relevant authorities.

I understand that the purpose of session recordings is to safeguard the interests of both client and counsellor.

I understand that all session recordings are kept under lock and key, and are deleted after six months.

Evaluation & Research

I agree to participate in post-session evaluation and counseling-related research conducted regularly by Focus on the Family Singapore Ltd to improve the quality of our counselling services.

We will respond to your submitted enquiry within 2 working days.

In the event of a crisis & you are unable to reach us, please do not wait for us to respond to you. Please call Samaritans of Singapore (SOS) at 1800 221 4444 or in extreme cases of danger, the police. Both operate 24/7. Stay on the phone with them until someone comes to you. Or, you can head down to the Accident & Emergency (A&E) Department of your nearest hospital.

Fees

Type of session	Individual (per hour)	Additional half hour charges (Individual)	Couple/Family (per hour)	Additional half hour charges (Couple/Family)
Day from 9.00am	$160	$80	$200	$100
Night from 6.00pm	$190	$95	$220	$110

*Last appointment for DAY - 5.00pm * Last appointment for NIGHT - 7.00pm

Note

1. Counselling session duration adheres to the scheduled time slot.

2. After the first hour, additional charges will apply per half hour, based on the

rates reflected above.

3. All First-Time appointments are subject to advance payment.

4. Subsidies are available for application and subject to approval.

5. For any enquiries, you may call 6491 0700 (Monday - Friday, 9 AM to 6 PM), or

check out our website for FAQ.

Our cancellation policy

There will be no refunds for cancellations or no-shows upon confirmation of counselling appointments.

Request for rescheduling of appointment must be communicated via email or WhatsApp at least 1 working day before scheduled appointment.

A 50% administrative fee of the session rate will apply for the rescheduling of appointments with less than 1 working day's notice.

Please indicate:*

I accept the Statement of Informed Consent and its terms and conditions, including the intent of session recordings, evaluation and research.
I would like to receive complimentary family-life resources from Focus on the Family Singapore.

Marriage contentParenting content
In providing your personal information, you allow Focus on the Family Singapore to use the information to facilitate the provision of the services stated. Please be assured we are committed to keeping your personal information secured. Find out more at www.family.org.sg/privacy-policy.
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Appointment Request