Please select the Counsellor you are working with, this form will be shared with them only. —Please choose an option—General (Support Team)Bonnie LiEmerald ShekKristin NgJimmy WanIndra LalSuzanne ShingTuna Cheung
First Name in English
Surname in English
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 if you received any diagnosis:
Are you taking any psychiatric medication? NoYes
If yes, please list the psychiatric medication(s) you are currently taking (medication name, dosage, frequency, prescribing doctor) :
How would you rate your current physical health? —Please choose an option—Very GoodGoodSatisfactoryUnsatisfactoryPoor
How would you rate your current sleeping habits? —Please choose an option—Very GoodGoodSatisfactoryUnsatisfactoryPoor
How would you rate your appetite during the past two weeks? —Please choose an option—Very GoodGoodSatisfactoryUnsatisfactoryPoor
Have you experienced overwhelming feelings of sadness or grief in the last two weeks? —Please choose an option—NoYes
Did you experience any significant life changes or stressful events recently? —Please choose an option—NoYes
If yes, please describe the changes or stressful event briefly
Do you have any religious affiliations? —Please choose an option—NoYes
If yes, please indicate your faith or belief (optional)
Please answer the following questions based on the past one month.
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? EnglishCantoneseMandarin
Mindology is not suitable for your situation. Please kindly refer to this link for external support which you may find beneficial.
