保密客戶資料 Confidential Client Information

姓名 Your complete name（必填）

電子郵箱 Email （必填）

微信 Wechat ID

地址 Address（必填）

區 Suburb（必填）

聯絡電話 Contact number（必填）

性別 Gender

年齡 Age

出生日期 Birthdate

出生地點 Birthplace

教育程度 Education (grade completed, any post secondary)

現時職業 Current Occupation

緊急聯絡人及聯絡電話 Person to alert in the event of medical emergency and phone number

與您的關係 Relationship to you

家庭醫生及聯絡電話 Family Doctor and phone number

關係狀況（請選一個）Relationship status (check one)

Single單身Married已婚Partnered同居Separated分居Divorced失婚Widowed喪偶

配偶名字 Spouse/partner’s name

配偶年齡 Spouse/partner’s age

關係年期 Years in relationship

子女（性别，年齡）Children (gender, age)

請描述任何目前或過去的重大醫療狀況／手術等。Please describe any significant current or past medical problems

若您目前正在服用藥物，請詳列藥物名稱、服用狀況及方式（包括處方或非處方藥物）。Please list any medications you currently take. Include prescription and over-the-counter medications and the dosage of each

請問您是否曾經或正在接受專業心理健康照護或輔導? Have you had previous psychological care or counselling?

Yes是No否

上題若回答是，請提供心理專家的姓名、就診期間（如11月14日-2月15日）及當時經歷的困擾／就診原因。If yes, please give the name of the clinician(s), the months you saw them (eg, Nov 14 - Feb 15), and the nature of the difficulty at the time

請問您是否曾經因為心理健康問題入院接受治療? Have you ever been hospitalised for a psychological difficulty?

Yes是No否

上題若回答是, 請詳述日期及入院原因／當時經歷的困擾。If yes, please give the dates and the nature of the difficulty at the time

您希望在心理諮詢中最想解決或處理的問題是什麼？請隨心所欲地描述。 In your own words, what is the nature of the concern that you wish to address in counselling? Feel free to describe this in as much or as little detail as you wish.

為了有效地讓諮詢協助您解決困難，有明確及具體的目標會事半功倍。您可能會認為以目標的形式表達您希望透過諮詢得到什麼並不容易，但請至少沉思一下，作出初步的努力。您可以同時列出多個目標, 並與您的諮詢師一起進一步討論。 Counselling can be a powerful force for change. In order for it to be most effective it helps to have a clear and specific goal. You may find it difficult to express your hopes for counselling in the form of a goal, but please make at least an initial effort. You can discuss this further with your counsellor. Feel free to list more than one goal if you wish.

請認真閱讀以下免責聲明和協議，勾選框即表示您已經閱讀、同意並接受聲明和協議中所列的各項及所有適用條款。Please read our Disclaimer and Agreement below and tick the box to confirm that you have read, understand and accept each and every clause of it.