PSBA_StudentCare_RequestForm

Student Care & Guidance

CONFIDENTIAL
Request for Counselling / Learning Support Services
IMPORTANT NOTE:

Confidentiality
Please note that all personal information gathered by Student Care & Guidance during the provision of counselling or learning support services will remain confidential except when:
1. There is legal obligations to disclose; or
2. Failure to disclose the information would place you or another person at risk

Code of Ethics
Counselling will be conducted in accordance to Singapore Association for Counselling (SAC)'s Codes of Ethics.

Personal Data Protection Act (PDPA)
All information provided is treated with the strictest confidentiality in accordance to PDPA (Singapore Personal Data Protection Act) requirements. PSB Academy respects the protection of personal data. By submitting your personal information, you expressly allow PSB Academy to contact you for counselling purposes. For more information on our data protection policy, please refer to http://www.psb-academy.edu.sg/pdpa.

Appointments are available on:

Tuesday to Thursday: 9am - 1pm (Last appointment slot at 12pm)
Alternatively, you may contact us at 6390 9214 or email to care@psb-academy.edu.sg for appointments.
Services Required*

Personal CounsellingLearning Support Services
Preferred Mode for Personal Counselling (subject to availability)*

Video Call (via Microsoft Teams)Face-to-Face at City Campus @ Marina Square, Main Wing
1st Appointment Preference Date*

DayMonthYear
2nd Appointment Preference Date*

DayMonthYear
Personal Particulars
Full Name (as per NRIC/Passport) *
Are you above 18 years old as of today? (Parent/Guardian consent is required if you are under 18 years old.)*

YesNo
Gender*
Date of Birth*

DayMonthYear
Date
Last 4 Characters of NRIC/FIN No.*
NRIC/FIN is S1234567A, fill in only "567A"
Which country are you from?*
Race*
E.g. Chinese, Malay, Indian, Eurasian, etc
Marital Status*
Contact Details
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address*
Our main mode of contact will be via email. Please ensure accuracy in email address.
Mobile Number*

Country Code/Area CodePhone Number
Programme Information
Study Load*

Full-TimePart-Time
Course Commencement Date*

MonthDayYear
Date
Name of Programme*
Name of Institution*
e.g. Coventry University, La Trobe University, PSB Academy, etc
Emergency Contact

Please provide next-of-kin contact in case of emergency.
Name of Emergency Contact*
Relationship*
e.g. Mother, Father, Brother, Sister, Friend, etc
Mobile Number*

Country Code/Area CodePhone Number
I, hereby, indicate that I have read the above and have given consent for the collection and use of the above information for the purpose of counselling and learning support services sought by me. *

Clear
Informed Consent for Minors Below 18 Years Old

For parent/guardian of student: Please read the below carefully prior to signing.
Confidentiality

All information disclosed within the sessions is confidential and may not be revealed to anyone without your permission, except to those to whom counsellors owe accountability for counselling work or on whom counsellors rely for support and supervision. In this specific setting, parent/guardian is involved in the process through consultation. Thus, relevant information will be provided to the parent/guardian for treatment. Other areas of confidentiality will be discussed during the first session with the child in the presence of their parent/guardian (if possible) to ensure complete understanding and agreement prior to the initiation of counselling.

Acknowledgment and Consent:

By your signature below, you are indicating that you read and understood this consent form or that any questions you had about this consent form were answered to your satisfaction.
I consent that my child, Name of Child* , may be treated as a student by the PSB Academy Counsellor. This form is in effect from Date* until the end of his/her studies in PSB Academy.
Parent/Guardian's Signature*

Clear
Date

DayMonthYear
Date
Should be Empty:

Student Care & Guidance

Request for Counselling / Learning Support Services

Personal Particulars

Contact Details

Programme Information

Emergency Contact

Informed Consent for Minors Below 18 Years Old