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【沟通心理学】线上课程
【心灵疗愈课】线上课程
【财富能量密码】线上课程
【导师班】国际认证催眠治疗师证书课程
心灵咨询疗程
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一对一心灵咨询疗程
催眠疗程
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了解催眠
一对一催眠疗程
催眠治疗师团队
预约疗程
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客户疗程表格
Client Intake Form
OM SPACE WELLNESS CENTRE
"
*
" indicates required fields
客户个人资料 Client Information Details
全名 Full Name per IC / ID
*
Mr
Ms
Mrs
Dr.
Dato
Dato
Datin
Dato Sri.
Datin Sri.
Prefix
Full Name per IC
洋名 Nickname
身份证号码 IC / ID No.
*
生日日期 Date of Birth
*
Day
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Month
1
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Year
2023
2022
2021
2020
2019
2018
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2016
2015
2014
2013
2012
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1934
1933
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
性别 Gender
*
男 Male
女 Female
电话号码 Phone Number
*
电邮 Email
*
地址 Address
*
地址 Stress Address
花园 Area
城市 City
州属 State
邮政编码 Postcode
国家 Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
职业 Occupation
您如何得知我们的中心?How do you get to know us?
*
Facebook
Google / Website
Youtube
线下课程 Workshop / Courses
家人朋友介绍 Referral by Friends and Family
其他 Other
其他 Other
个人医学病历 Medical History
目前是否在接受心理医生或心理咨询师的治疗?如果有,请填写治疗师姓名。
*
Are you currently under a physician/ therapist's care? If Yes, kindly provide the therapist name.
是 Yes
否 No
心理医生 / 治疗师姓名 : (如有)
Practitioner / Therapist Name: (if Yes)
目前是否在使用任何药物? 如果有,请填写药物的名称。
*
Are you currently under any medication? If Yes, kindly write down the name of the medication.
是 Yes
否 No
药物名称:(如有)
Name of the medication: (if Yes)
目前是否有任何的生理上的问题或不适?如果有,请填写生理问题的情况 。
*
Do you have any medical issue? If Yes, kindly write down the medical condition.
是 Yes
否 No
生理问题(例如心脏病/哮喘等等): (如有)
Medical Condition (Eg: Asthma / Heart Attack): (if Yes)
疗程详情 Therapy Session Details
咨询的原因 Reason of Visit
*
个人心理 Personal
健康问题 Health Issue
感情咨询 Relationship
婚姻咨询 Marriage
家庭 Family
人际关系 Interpersonal Relationship
事业 Career
财富 Financial
其他 Other
其他原因
Other Reasons
请问您之前是否有接触过心理咨询 / 催眠疗程?如果有,请填写疗程后的成果。
*
Have you experienced Psychotherapy or Hypnotherapy before? If Yes, kindly share with us the outcome.
有 Yes
没有 No
之前的疗程效果:(如有)
Previous outcome: (if Yes)
您希望透过心灵咨询 / 催眠疗程达到什么成果?请列出您想要达到的目标。
*
What is your goal from this therapy session? Kindly list down your desired goals in order of priority:
选择语言
*
Choose your preferred language
华文 Mandarin
英文 English
广东话 Cantonese
福建话 Hokkien
请问你想透过线上或者线下进行疗程?
*
what medium would you prefer to conduct the session?
线下 at Om Space Wellness Centre
线上 Online - Zoom
两个都可以 Both
疗程同意书 Informed Consent Form
*
我特此完全同意并接受 Om Space Wellness Centre 心理治疗师的治疗疗程。
- 我了解通过疗程获得的结果是因人而异的,并且没有特定的结果保证。
- 我了解疗程不能替代医学或心理治疗方法或辅导。
- 我了解治疗师不会诊断或开处方关于任何身体或精神疾病状况
- 我了解在某些情况下,治疗师可能需要触碰手,手腕,手臂,肩膀或额头的部分,以帮助我建立更放松的状态,我特此同意治疗师的这种抚触
- 我已尽我所能参加每次的疗程。
- 我已按照治疗师的要求准确的提供了相关信息。
- 我了解所有治疗疗程都是隐私和保密的。
- 未满18岁的客户也同样会受到相关的隐私保护。
- 疗程配套可在18个月内进行疗程,期间可兑换其他疗程但恕不退款。
- 我了解并同意Om Space Wellness Centre的退货和退款政策。
I hereby give my full consent to receiving therapy session by Certified practitioner at Om Space Wellness Centre.
- I understand that the results obtained through the therapy session may be vary for each individual and no specific results can be guaranteed.
- I understand that the therapy session is not a replacement for medical or psychological treatment or counselling.
- I understand that the practitioner does not diagnose or prescribe for any physical or mental conditions.
- I understand that in some circumstances it may be necessary for the practitioner to respectfully touch me on the hand, wrist, arms, shoulder or forehead as a means of helping me establish a beneficial state of relaxation, I hereby consent to such touching by the practitioner.
- I have agreed to participate in each session to the best of my ability.
- I have accurately provided background information as requested by the practitioner.
- I understand that the consent of all therapy sessions is private and confidential.
- Confidentially is also respected when the client is under the age of eighteen.
- All session package is valid for 18 months, in the validity of 18 months, client may change to other sessions but no refund and return is allowed.
- I hereby also agreed with Om Space Wellness Centre Return and Refund Policy.
是 我同意 / Yes, I am aware and agree
签名 Signature
*
家长/监护人签名(如果客户是18岁以下)
Signature of Parent / Guardian (if the client is under the age of 18)
Phone
This field is for validation purposes and should be left unchanged.
Our Customer Support Team is here to answer your questions. Ask us anything!
Joanne
Customer Careline
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Gilbert
Customer Careline
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Teddy
Customer Careline
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