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    Client Intake Form


    General Information


    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

    Have you previously received any type of mental health services (counselling, clinical psychology, psychiatric services, etc)?
    NoYes

    Please indicate: 1) The reasons that led you to seek support in the past? 2) The name of the practitioner you consulted 3) If any, the diagnosis you received?

    Are you taking any psychiatric medication?
    NoYes

    Please indicate: 1) the medication, 2) dosage, and 3) name of the 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.

    GAD-7


    Over the last two weeks, how often have you been bothered by the following problems?

    Feeling nervous, anxious, or on edge 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Not being able to stop or control worrying 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Worrying too much about different things 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Trouble relaxing 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Being so restless that it is hard to sit still 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Becoming easily annoyed or irritable 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Feeling afraid as if something awful might happen 0 Not at all1 Several days2 More than half the days3 Nearly every day

    PHQ-9


    Over the last two weeks, how often have you been bothered by the following problems?

    Little interest or pleasure in doing things 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Feeling down, depressed, or hopeless 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Trouble falling or staying asleep, or sleeping too much 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Feeling tired or having little energy 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Poor appetite or overeating 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Trouble concentrating on things 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidigety or restless that you have been moving around a lot more than usual 0 Not at all1 Several days2 More than half the days3 Nearly every day
    Thoughts that you would be better off dead or of hurting yourself in some way 0 Not at all1 Several days2 More than half the days3 Nearly every day

    Wellbeing

    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?

    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

    Please indicate your faith or belief (optional):

    Reasons for seeking counselling


    Select all options that apply:
    StressAnxietyLow MoodAngerRelationshipsFamilySexualityTraumaGriefParentingSelf-WorthBehavioural ConcernsEating DisordersAddictionsSpecial NeedsPersonal-GrowthLife TransitionsCaregiver SupportOthers

    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 with your counsellor?
    EnglishCantoneseMandarinJapaneseHindi

    YesNo

    Name: Relationship: Email: Phone: