Therapy and Assessment Registration
Please fill out the form to register for mental health support and services.
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Full Name
*
First Name
Last Name
Preferred name
*
example@example.com
Pronounce
Please Select
She/Her
He/Him
They/Them
Others
If others, please specify
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (+65) 0000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Briefly describe the reason you are seeking mental health services
*
Preference in therapist (Fees start from $120 per session. We believe therapy should be accessible, and fee adjustments may be considered for those facing financial hardship)
*
Gerald (Senior Counselling Psychologist)
Merissa (Senior Educational Psychologist)
Xin Rui (Art Psychotherapist & Parent Coach)
Vincent (Psychologist)
Simone (Psychologist)
Wei Ting (Associate Counsellor)
No preference (We will match you to someone suitable in our team!)
Would you like to be considered for a reduced fee due to financial difficulties? If yes, please briefly share any information you would like us to consider when reviewing your request for a reduced fee.
Are you looking to also see a psychiatrist? (Do note that they are medical doctors who are able to prescribe medication)
*
Yes
No
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (+65) 0000-0000.
Register
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