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 and cancellation policy

  I agree to the published session fee and to the 48-hour cancellation policy. Sessions cancelled with less than 48 hours' notice are charged in full unless otherwise agreed.
• 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.