Please select the Counsellor you are working with. This form will be shared with them only. —Please choose an option—General (Support Team)Bonnie LiCanis LinEmerald ShekJimmy WanKristin NgIndra LalMiu ChengSuzanne ShingTuna Cheung
Full Name (as indicated on your HKID)
HKID (first four letters/digits)
Email
Phone
Age
If this intake form is for an individual below the age of 18 years old, please fill the following information by a Parent or Guardian
Parent/Guardian First Name in English:
Parent/Guardian Surname in English:
Parent/Guardian Mobile Number:
Parent/Guardian Email Address:
Gender —Please choose an option—MaleFemaleNon-binaryPrefer not to respond
Sexual Orientation —Please choose an option—HeterosexualHomosexualBisexualPrefer not to respond
Relationship Status: —Please choose an option—SingleIn a relationship (not married)MarriedSeparatedDivorcedWidowed
Education Level —Please choose an option—No Formal EducationPrimary SchoolSecondary SchoolVocational SchoolUndergraduate DegreePostgraduate Degree
Have you previously received any type of mental health services (counselling, clinical psychology, psychiatric services, etc)?: NoYes
If yes, please indicate: 1) What were the reasons that led you to seek mental health services in the past? 2) The name of the practitioner you consulted 3) What diagnosis did you receive (if any), and when was it given?
Are you taking any psychiatric medication? NoYes
If yes, please provide the following details for each psychiatric medication you are taking: medication name, dosage, frequency, and prescribing doctor:
* Please email support@mindology.hk any previous diagnostic reports or therapy session notes that may help us tailor our support to your needs.
Please answer the following questions based on the past two weeks:
Feeling nervous, anxious or on edge Not at all (0 days)Rarely (1 to 3 days)Sometimes (4 to 7 days)Often (8 to 10 days)Nearly every day (11 to 14 days)
Not being able to stop or control worrying Not at all (0 days)Rarely (1 to 3 days)Sometimes (4 to 7 days)Often (8 to 10 days)Nearly every day (11 to 14 days)
Feeling down, depressed or hopeless? Not at all (0 days)Rarely (1 to 3 days)Sometimes (4 to 7 days)Often (8 to 10 days)Nearly every day (11 to 14 days)
Had little interest or pleasure in doing things? Not at all (0 days)Rarely (1 to 3 days)Sometimes (4 to 7 days)Often (8 to 10 days)Nearly every day (11 to 14 days)
How would you rate your physical health? —Please choose an option—GoodAveragePoor
How would you rate your sleeping quality? —Please choose an option—GoodAveragePoor
How would you rate your appetite? —Please choose an option—GoodAveragePoor
Did you experience any significant life changes or stressful events? —Please choose an option—NoYes
If yes, please briefly describe the changes or stressful event
Have you ever had any thoughts of harming yourself? NoYes
Have you ever attempted to harm yourself? NoYes
Have you ever harmed yourself to the extent where your life was at risk? NoYes
Do you have any religious affiliations? NoYes
If yes, please indicate your faith or belief (optional):
Select all options that apply: RelationshipsEmotionsStress/AnxietyLow MoodAngerTraumaGriefFamilyParentingCaregiver SupportEating DisordersSexualityAddictionsSelf-WorthSpecial NeedsPersonal-GrowthLife TransitionsOthers
Please briefly describe the reasons for seeking counselling and what you hope to accomplish during the process:
Which language would you prefer to communicate in? EnglishCantoneseMandarinJapaneseHindi
Would you like to provide an emergency contact?
YesNo
Name: Relationship: Email: Phone:
At Mindology, we aim to provide support for specific types of concerns, and we want to ensure you receive the most appropriate care. Since your responses suggest that you may need specialized or crisis support, we recommend reaching out to the resources at this link .
