Appointment Request

Please complete the form below to request for an appointment with our counsellors or therapist.

We will contact you within 1 business day. You will need about 10 mins to complete the form.

Appointment Request Information


Preferred Date of Appointment (Mon - Sat)*
Preferred Time*
Mode of Counselling*
Counselling Type*

Each session is approximately 60 mins (A) Individual Therapy at SG$150 per session, (B) Couple/Family Therapy at SG$180 per session. Payment will only be made after session is completed

Package rates are applicable ( 4 Sessions Package at 10% Discount). Refer here for more information

Issue seeking help for:*

Personal Particulars

Name*
Address*
Gender*
Mobile Hp*
E-mail*
Race*
Nationality*
Country of Origin*
Age*
Religion*
Educational Level*
Occupation*
Marital Status*
Number of Years of Marriage
Name of Partner (for Couple/Marriage counselling)
Do you have any previous counselling experience?*
Please provide a brief description of Issue
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Confidentiality and Cancellation Policy

Please read through and acknowledge at bottom of page.

LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian. Noted exceptions are as follows:


Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities.
In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the clients' records.

Insurance Providers (when applicable)
Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.


When the information is subpoenaed by governing authorities
When there is an order from the Court to request for information, we will make reference to the Court's instruction. We will keep all parties involved of the Court's instructions (unless otherwise instructed by the Court), and will try to work towards a consensual release of privileged information of the client(s).

CANCELLATION POLICY

If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment.

A full session fee is charged for missed appointments or cancellations or rescheduling of appointments with less than a 24-hour notice unless it is due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for, or cancel or reschedule an appointment with less than 24 hours notice.

Thank you for your consideration regarding this important matter.

I have read and acknowledge the Confidentiality and Cancellation Policies*
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