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Initial Information

All information you provide here is strictly confidential by PSYCHUB and used solely for consultation and psychological therapy purposes. Information marked with (*) is required and must not be left blank.

Full Name: (*)

Please let PSYCHUB know your gender: MaleFemale

Are you booking the appointment for (yourself or a family member)(*) : YourselfFamily member

Phone number (*):

Email (*) :

Place of residence

Year of birth (*) :

If booking for a family member

Phone number of the person receiving consultation/therapy:

Email of the person receiving consultation/therapy:

Year of birth of the person receiving consultation/therapy:

Relationship to the family member:

About Your Mental Health Concerns

To complete your consultation appointment, please take a few minutes to answer the following questions. The more detailed and clear the information you provide, the more helpful it will be for PSYCHUB in supporting you with your concerns or difficulties.

1. Please briefly describe your main issue: (*)

2. How long has this issue occurred or persisted? (*)

3. What methods have you tried to cope with this difficulty? (You may select multiple options) (*) Tried to overcome it on my ownSought help from family/relativesSought help from friendsParticipated in therapy or professional support servicesSought help via social mediaOther

4. What expectations do you have for the consultation - therapy process (regarding specialists, session duration, support policies, outcomes, etc.)

Appointment Information

1. Which consultation method do you prefer? (In-person, Online, Both)(*) : In-personOnlineBoth

2. How would you prefer PSYCHUB to contact you? (*) EmailPhone numberOther

Discount code (if any)

Initial Information

If booking for a family member

About Your Mental Health Concerns

Appointment Information

Bộ phận hỗ trợ

Thông tin liên hệ

Shophouse SH07, Tòa Aqua 2, Vinhome Golden River, Phường Sài Gòn, TP. HCM

Số điện thoại liên hệ

Email

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