APKIM Private Counselling Registration
All information provided is strictly confidential
Email
*
example@example.com
Name of Client
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Age
*
Marital Status
*
Please Select
Single
Engaged
Married
Separated
Divorced
Widowed
Religion
*
Please Select
Islam
Christianity
Buddhism
Hinduism
No religion
Others (Please fill below)
Religion
Phone Number
*
Employment Status
*
Please Select
Student
Full / Part-Time Employed
Self-Employed
Unemployed
Retired
Others (Please fill below)
Employment Status
Gross monthly income
*
Please Select
Less than $2000
$2001 to $5000
$5001 to $10000
more than $10000
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Please select your preferred appointment date. An email will be given to confirm which appointment is available or explore other alternative slots, hence do check and respond to the email.
Appointments will be subject to counsellors availability. We are not open on weekends and public holidays.
Counselling Session
*
Please select an alternative appointment date
Please provide an alternative slot of at least 2 weeks from now. Our office with update on the availability of the slot you have requested.
Alternative Date of Counselling Session
*
If you already have a Counsellor in mind, please indicate the name of the Counsellor. Otherwise, APKIM will select a Counsellor best suited to your profile.
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Type of Counselling Service requested
*
Please Select
Marital / Pre-Marital Counselling / Couples Therapy
Individual Counselling
Family Support
Unplanned Pregnancies
Trauma, Grief & Loss Counselling
Self-Exploration & Personal Growth
How did you find out about APKIM Counselling Service?
*
Web search
APKIM's Social Media Pages
Recommendations by friends/family
Referred by other agencies
Islamic Mental Health Convention
Others (Please fill below)
How did you find out about APKIM Counselling Service?
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Marital Details
Date of Marriage
*
-
Day
-
Month
Year
Date
Name of Partner
*
First Name
Last Name
Age of Partner
*
Partner's Occupation
*
Your Occupation
*
Will you be attending with your partner?
*
Please Select
Yes
No
Maybe
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Marriage
This segment is regarding your views of your marriage. The range 1 indicates ''Never' and 5 indicates Äll the time'.
In general, how often do you think that things between you and your partner are going well?
*
Never
1
2
3
4
All the time
5
1 is Never, 5 is All the time
Do you confide in your partner?
*
Never
1
2
3
4
All the time
5
1 is Never, 5 is All the time
Does your partner confide in you?
*
Never
1
2
3
4
All the time
5
1 is Never, 5 is All the time
How often do you discuss, or have you considered divorce, separation, or ending your relationship in the last 12 months?
*
Never
1
2
3
4
All the time
5
1 is Never, 5 is All the time
Sometimes couples are leaning in different directions about the future of their marriage. Please select the number below that is closest to your own “leaning” at this moment. The lowest (1) indicate the leaning to strongly working on preserving the marriage while the highest (10) indicate leaning to definitely ending the marriage.
Where are you leaning toward at the moment?
*
Strongly working on preserving the marriage
1
2
3
4
5
6
7
8
9
Definitely ending the marriage
10
1 is Strongly working on preserving the marriage, 10 is Definitely ending the marriage
Where do you think your partner is leaning toward?
*
Strongly working on preserving the marriage
1
2
3
4
5
6
7
8
9
Definitely ending the marriage
10
1 is Strongly working on preserving the marriage, 10 is Definitely ending the marriage
Which concerns below apply to your marriage/family
*
Conflict on our parenting style
How my partner handle finances
Growing apart
My partner does not give me enough attention
We are not able to discuss in a satisfactory manner
My partner’s friends
My partner’s leisure activities
My partner’s personal habits
In-law issues
How we divided household responsibilities
Religious differences
Alcohol or drug problems
Personal problems of my spouse
Infidelity
My partner works too many hours
Sexual problems
How we divided childcare responsibilities
Physical violence
Differences in our tastes and preferences
Pornography
Other concerns- please describe the concerns in the next question
Issues and concerns you would like to highlight to the Counsellor
Did you attend the Marriage Preparation Course?
*
Yes, I attended at APKIM (@ Arab Street/CT Hub)
Yes, I attended at Mosques/other Private Operators
No, we did not attend any Marriage Preparation Course.
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APKIM Family
As an APKIM Marriage Preparation Course participant, you are a part of the APKIM family and are entitled to 1 complimentary Counselling/Consultation session if your marriage is below 10 years.
Would you like to redeem your complimentary session if your marriage is less than 10 years?
*
Yes. I will email to info@apkim.com both our full names and year of course for APKIM to verify my particulars. I and/or my spouse have not redeemed our complimentary session before this.
No. I have already redeem my complimentary session before this or my marriage is already more than 10 years.
No. I prefer not to redeem and will make the necessary payments instead.
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Complimentary Session
Your Full Name
*
First Name
Last Name
Your Spouse's Full Name
*
First Name
Last Name
Date or Year of Course
*
Please upload an image of your APKIM Marriage Course Certificate
*
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Relevant Details
Details of People relevant to your situation (Name, Age, Relationsip)
*
Key Issues and concerns you would like to highlight to the Counsellor
*
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Family Details
Details of Family Members (Name, Age, Relationship)
*
Key Issues and concerns you would like to highlight to the Counsellor
*
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Details of Unplanned Pregnancy
Details of Relevant People involved( Name, Age, Relationship & any other relevant information)
*
Key Issues and concerns you would like to highlight to the Counsellor
*
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Payment
Counselling Fee is $160 per hour. Please make payment via PAYNOW by scanning the QR code, or inputting APKIM Resources UEN 49696000L001.
Please upload a screenshot of the receipt
*
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Please upload a picture/screenshot of your Student ID
*
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*
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