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Part — 1
PARTICULARS OF APPLICANT (1 OF 2)
First name
Last name
Contact Number
Email address
Age
Birthdate
Passport / ID Number
Occupation
PARTICULARS OF APPLICANT (2 OF 2)
Gender identity (select all that apply)
Male
Female
Transgender Male
Transgender Female
Gender Queer
Additional category
Decline to answer
Assigned sex at birth (select one)
Male
Female
Other
Decline to answer
Preferred pronouns (select all that apply)
She / her / hers
He / him / his
They / them / theirs
Other
Current relationship status (select all that apply)
Single
Married
In a civil union
Domestic partnership (living together)
Partnered (not living together)
Divorced
Widowed
In a comitted relationship
Other
Part — 2
EMERGENCY CONTACT DETAILS
Full name
Contact number
Email address
Relationship
Part — 3
WHICH OF THE FOLLOWING DO YOU HAVE EXPERIENCE WITH
Select all those that apply
Email
Encrypted email
Blogging
Online forums
Texting
Gaming
Instant messaging
Video calls
Online payments
Social network apps
Memes
Part — 4
PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS
Have you ever been treated by a therapist/counsellor before? If so, when and for what?
Are you currently being treated by a therapist/counsellor?
Are you currently on any medication? If yes, please list your medication
How often do you drink alcohol?
How often do you do recreational drugs?
Have you ever been hospitalised for drug abuse or alcohol abuse, suicide attempts, or other mental health concerns? If so, please give the approximate dates and circumstances
What is your overall health like?
Do you have any medical problems now or in the past that would be helpful for me to know about?
It would be helpful to know about your family of origin, what your childhood was like, and anything else about what your family and life like growing up
Have you ever felt in the past like harming yourself or someone else?
Do you have those feelings now?
Is there anything else about you I should know such as ethnicity, gender preference, or sexual identity?
How many hours a day do you spend on your model device/computer?
Do you have any other concerns about finding balance in your life with issues such as exercising, gambling, sexual activity, food, etc.?
If you have a partner, how long have you been together?
If you have children, please give their names and ages
Who lives with you?
What is your highest level of education?
Reasons for the referral / motivation for therapy
What are you hoping to achieve in therapy?
SUBMIT FORM
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