Intake

Please provide the following information for our records. Please fill in all fields even if you plan to discuss this with your therapist. Information you provide here is held to the same standards of confidentiality as therapy. Please note that a cancellation fee (up to 100%) applies if you cancel within 48 hours of a scheduled appointment.

Sections A - E

A terms page for signature will pop up upon submission of this Intake form.

Full Name of Parent or Guardian

Parent or Guardian

Mother

Father

Other Relative

Guardian

Date of Birth

of Parent / Relative / Guardian

YYYY

E-mail Address

Contact Number (Mobile)

Residential Address

Child's Details

Child's Full Name

Child's Date of Birth

YYYY

Nationality

Child's Contact Number

Child's NRIC/Passport

Please fill in last 4 alphanumeric of the Child's NRIC or Passport Number

Residential Address

Emergency Contact

Emergency Contact Person

Emergency Contact Number

Home and/or Mobile

Relationship to Child

Caregiver's Questionnaire

Section B

Parent / Guardian #2

Please fill in details of the other parent/guardian (if any)

Date of Birth

YYYY

Country of Birth

Race

Occupation

Spoken Languages

Intake

Child Health and Wellbeing Roadmap

Our Purpose

About Us

Operating Hours

Contact Us

Getting Here

Allied Health Professionals