Choices Enquiry Form
Hi, please fill in this short form to let us know how we can be of service to you through Choices Ministry.
Name
*
First Name
Last Name
Contact Number
*
Email
*
example@example.com
Preferred mode of contact (you may select more than 1)
*
Email
Phone Call
Text
Preferred time to be contacted
*
Eg. Between 2pm to 9pm
Sex
*
Female
Male
Prefer not to say
Age Range
*
Under 12
13-17
18-25
26-35
36-45
46-55
56-65
66-75
Above 75
Employment Status
*
Studying
Employed part-time
Employed full-time
In-transition / Unemployed
Religion
*
Christianity
Buddhism
Taoism
Islam
Hinduism
No religion
Other
Which of these services would you be seeking for?
*
Counselling
Support group
Befriending
Mentoring
Other
How did you come to know of Choices?
*
Please describe the issue(s) of concern briefly.
*
Personal Data Protection Act (PDPA): "By filling this form, you agree that Church of Our Saviour may collect, use, and disclose your personal data, as provided in this form, for the processing of this application with all relevant parties in accordance with the Personal Data Protection Act 2012."
*
I agree
Submit
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