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
First Name
Surname
Email
Phone
Gender —Please choose an option—MaleFemaleNon-binaryPrefer not to respond
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:
Relationship Status: —Please choose an option—In a relationship (not married)MarriedSeparatedDivorcedWidowedSingle
Education Level —Please choose an option—Primary SchoolSecondary SchoolPost-Secondary 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 medicine(s) you are taking: medication name, dosage, frequency, and prescribing doctor:
* Please email support@mindology.hk any previous diagnostic reports or counselling session notes that may assist us in gaining a better understanding of your situation.
Please answer the following questions based on the past two weeks: 0 - Not at all 1 - Several days (1 to 6 days) 2 - One week or more (7 to 12 days) 3 - Nearly every day (13 to 14 days)
Feeling nervous, anxious or on edge 0 - Not at all1 - Several days2 - One week or more3 - Nearly every day
Not being able to stop or control worrying 0 - Not at all1 - Several days2 - One week or more3 - Nearly every day
Feeling down, depressed or hopeless? 0 - Not at all1 - Several days2 - One week or more3 - Nearly every day
Had little interest or pleasure in doing things? 0 - Not at all1 - Several days2 - One week or more3 - Nearly every day
How would you rate your physical health? —Please choose an option—GoodSatisfactoryPoor
How would you rate your sleeping quality? —Please choose an option—GoodSatisfactoryPoor
How would you rate your appetite? —Please choose an option—GoodSatisfactoryPoor
Did you experience any significant life changes or stressful events recently? —Please choose an option—NoYes
If yes, please briefly describe the changes or stressful event
Do you have any religious affiliations? —Please choose an option—NoYes
If yes, please indicate your faith or belief (optional)
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
Emergency contact (optional)
Name: Relationship: Email: Phone:
Please indicate the reason(s) that brings you to counselling (you may choose more than one): Emotional issuesDepressionAnxietyRelationshipsTraumaGriefEating DisorderAddictionBehavioural issuesSelf-growthLife and family planningCoachingCareerSchoolCultural issuesOthers
Please briefly describe the reasons that bring you to counselling and what you would like to accomplish during the process:
Which languages would you prefer to conduct your sessions in? EnglishCantoneseMandarinJapanese
Mindology is not suitable for your situation. Please kindly refer to this link for external support which you may find beneficial.
