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    Intake Form


    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

    Name of Parent/ Guardian:

    Parent/ Guardian HKID (first four letters/digits):

    Relationship to child:

    Parent / Guardian Email Address:


    Gender

    Sexual Orientation

    Relationship Status:

    Education Level


    Previous Mental Health Support


    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.


    Wellbeing


    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?

    How would you rate your sleeping quality?

    How would you rate your appetite?

    Did you experience any significant life changes or stressful events?

    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):



    Reasons for seeking counselling


    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

    YesNo

    Name: Relationship: Email: Phone: