Registration Form 登记表格 Duration 90 minutes (First Session Only) Fees RM 200 (Opening Promo) Contact +6011-33445270 FAQ Read more 1. Method of Therapy / 治疗选项*Face to Face Therapy / 面对面心理治疗Online Therapy / 线上视频心理治疗a. Preferred device / 首选设备*Personal Computer / 个人电脑Smart Phone / 智能手机2. Full Name / 名字 (as per NRIC)*3. Email Address / 电邮* 4. Phone Number / 联络号码*5. Residential Address / 住址* Street Address City Zip / Postal Code State / Province Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 6. Birth Date / 出生日期* Date Format: DD slash MM slash YYYY 7. IC / 身份证号码*8. Preferred Method of Contact / 联络方式*Whatsapp TextPhone Call / 电话联系Email / 电邮9. Gender / 性别*Male / 男生Female / 女生Prefer not to say / 不方便透露10. Occupation / 职业*11. Preferred Language / 语言*English / 英语Malay / 马来Chinese / 华语12. Emergency Contact Name / 紧急联系人（名字）*13. Emergency Contact Number / 紧急联系人（联络号码）*14. Main reason to see a therapist / 咨询治疗师的主要原因*15. Have you experienced any psychotherapy previously? / 请问你之前有接受过心理治疗吗？*Yes / 有No / 没有16. In the past two weeks, how often have you been bothered by your thoughts that you would be better off dead, or of hurting yourself? / 在过去的两个星期，有多少时候你受到这个问题所困扰：不如死掉或用某种方式伤害自己的念头？*Not at all / 完全没有Several Days / 几天More than Half the Days / 一半以上的天数Nearly Everyday / 几乎每天17. Preferred Times for Appointment (e.g. Mon, 10am - 3pm), Tue (3pm to 6pm) / 适合的诊疗时间 (例如：星期一，10am to 3pm / 星期二, 3pm to 6pm)*Please suggest more than one time slot. We are open everyday, 9am-6pm, except Thursday. 请填写超过一个适合的诊疗时间。我们的营业时间是每天9am-6pm，星期四休息。18. How did you hear about us? / 你是如何得知我们的？* Google Facebook Friends or Family / 朋友或家人介绍 Other / 其他
