Psychotherapy

Someone we can contact in case of a clinical emergency.

Tick any areas you would like to bring to therapy.

• Anxiety, panic and chronic stress
• Depression and low mood
• Trauma or Stressor-related distress
• Relationships and Attachment
• Identity, culture and life transitions
• Body-Focused Repetitive Behaviours
• Obsessive Compulsive Disorder

For each domain, indicate how much it has bothered you in the past two weeks.

• Depression - feeling down, depressed, or hopelessSelect severity…NoneMildModerateSevere
• Anger - feeling more irritated, grouchy, or angry than usualSelect severity…NoneMildModerateSevere
• Mania - sleeping less but having lots of energySelect severity…NoneMildModerateSevere
• Anxiety - feeling nervous, anxious, frightened, worried, or on edgeSelect severity…NoneMildModerateSevere
• Somatic symptoms - unexplained aches and painsSelect severity…NoneMildModerateSevere
• Suicidal ideation - thoughts of actually hurting yourselfSelect severity…NoneMildModerateSevere
• Psychosis - hearing or seeing things others could notSelect severity…NoneMildModerateSevere
• Sleep problems - trouble falling, staying asleep, or sleeping too muchSelect severity…NoneMildModerateSevere
• Memory - problems with memory or concentrationSelect severity…NoneMildModerateSevere
• Repetitive thoughts and behaviours - unpleasant thoughts/urges or repeating actionsSelect severity…NoneMildModerateSevere
• Dissociation - feeling detached from yourself, surroundings, or memoriesSelect severity…NoneMildModerateSevere
• Personality functioning - not knowing who you really are or what you wantSelect severity…NoneMildModerateSevere
• Substance use - drinking, drug use, or medication misuseSelect severity…NoneMildModerateSevere

Please read and tick each clause. Submitting this form confirms a contractual agreement to the terms below.

• Informed consent to therapy

  I understand that psychotherapy involves discussion of personal, sometimes distressing material, and that outcomes cannot be guaranteed. I consent to engage in this process voluntarily.
• Confidentiality & its limits

  I understand that what I share is confidential, except where the clinician is legally or ethically obliged to disclose information (risk of serious harm to self or others, abuse of a minor or vulnerable adult, or court order).
• Fees, cancellation and refunds

  I agree to the published session fee. Cancellations made with at least 48 hours' notice are eligible for a partial refund of 80% of the session fee; the remaining 20% is retained to cover payment processing fees and the clinical time reserved for me. Sessions cancelled with less than 48 hours' notice, and missed sessions, are charged in full and are non-refundable.
• Data processing

  I consent to the secure storage of my contact details and clinical notes for the purpose of delivering care, in accordance with applicable data-protection law (PDPA / GDPR where relevant).
• Emergency acknowledgement

  I understand that this practice does not provide emergency services. In a crisis I will call 999 (Police) or 995 (Ambulance), the Samaritans of Singapore (SOS) 24-hour hotline on 1767, the IMH Mental Health Helpline on 6389 2222, or visit mindline.sg.