Mental Health Assessment Interest Form
A caseworker will be in contact with you within 3 working days upon submission of this form.
Full Name:
*
First Name
Last Name
Contact Number:
*
Please enter a valid phone number.
Sex:
*
Male
Female
Date of birth (Age has to be 12-25 years old)
*
-
Day
-
Month
Year
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Postal Code :
*
E.g. 150162
Area of concern (mental health related symptoms) :
E.g. low mood, negative thoughts, difficulties relating emotions, mentally distress experiences, anxiety, etc
What's causing you distress? (Please select what is applicable. There are no right or wrong answers!)
Academics
Exam stress
Fear of failure
Unrealistic expectations
Lack of motivation
Peer pressure
Bullying
Friendship conflict
Loneliness
Family conflict
Financial concerns
Excessive device use
Low mood
Low self-esteem
Anxiety
Emotional struggle
Poor appetite
Poor sleep
Unsafe environment
Identity confusion
Other
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ABOUT YOUTH INTEGRATED TEAM
Youth Integrated Teams (powered by Agency of Integrated Care) are allied health led teams in the community providing assessment and intervention, while engaging youths for ongoing monitoring and support. Where applicable, the teams may work actively with other involved youth agencies, schools and community partners to provide holistic case management for the youths and their families. By agreeing to this service, data collected and used for the purposes of program monitoring and evaluation, and may be disclosed to AIC.
I understand that all information regarding counselling is confidential and will not be released to any agency or individual without my prior knowledge and written consent, except when required by law. I understand that my counsellor may break confidentiality if I express a serious intent to harm others or myself. I understand that my counsellor is required to report apparent child abuse, elderly abuse, neglect and severe risk of harm to authorities.
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I agree
I understand that because here is a need to continuously improve level of services, all counselling sessions are recorded. The electronically recorded sessions are used to monitor the skill levels of counsellors and also to ensure the safety of clients. I understand that my counsellor may consult with other professionals or supervisors in TOUCH Counselling & Psychological Services. All records are kept within the premises of the organization and may be used for internal supervision.
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I agree
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What day is better for you?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Submit
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