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Cht.Rachel Foo
Msc.Cheong Meisi
Cht.Irene Tan
Cht.Justine Ng
Mr.Tan Kok Meng
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客户疗程表格
Client Intake Form
OM SPACE THERAPY CENTRE
"
*
" indicates required fields
尊敬的客户,我们将协助您以最快的速度进行专业疗程预约,为此,我们建议您花5分钟的时间填写以下的客户疗程表格以让我们的专业治疗师了解您的情况,并在完成后提交表格。 我们的服务顾问团队将在12小时内与您联系并为您安排预约。 感谢您的配合与耐心!
Dear Client, we would like to assist you to book appointment as fast as we can, to do so, we recommend that you may take 5 minutes to fill in the Client Intake Form to let our professional therapists understand your situation and submit the form once completed. Our Customer Service Team shall contact you and arrange the appointment for you within 12 hours. Thank you for your cooperation and patience!
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
*
DD
1
2
3
4
5
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11
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31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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1930
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1927
1926
1925
1924
1923
1922
1921
1920
性别 Gender
*
男 Male
女 Female
其他 Other
联络电话 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
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
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 Island 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
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
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 Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
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 and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
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?
*
Google / Website
Facebook
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
目前您或您的孩子(客户)是否在接受精神科医生、辅导员或心理治疗师的治疗?如果有,请填写以下资料。
*
Are you or your child (The Client) currently receiving treatment from a psychiatrist, counselor or psychotherapist? If yes, please fill in the following information.
是 Yes
否 No
治疗师姓名 : (如有)
Practitioner / Therapist Name: (if Yes)
是否有任何诊断?
Any diagnosis from the physician?
有 Yes
没有 No
请写下诊断名称 (如:忧郁症、发展迟缓、思觉失调症….)
Kindly write the name of the diagnosis (eg: depression, developmental delay, schizophrenia….)
何时开始有诊断?(年份)
When did the diagnosis begin? (year)
目前或曾经是否有接受过治疗?
Are you currently or have you ever received treatment?
是 Yes
否 No
请问是哪一种治疗?
What kind of treatment is it?
职能治疗 Occupational Therapy
语言治疗 Speech-language Therapy
物理治疗 Physiotherapy
感觉统合治疗 Sensory Integration Therapy
其他(请说明)Other
其他治疗 Other Type of Treatment
何时开始接受治疗?(哪一年至哪一年? 例如:2020年 - 2022年)
When did you start treatment? (from which year to which year? Example: 2020 - 2022)
目前您或您的孩子(客户)是否在使用任何药物? 如果有,请填写药物的名称。
*
Are you or your child (The Client) currently taking any medications? If yes, kindly write down the name of the drug.
是 Yes
否 No
药物名称:(如有)
Name of the medications: (if Yes)
目前您或您的孩子(客户)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 。
*
Are you or your child (The Client) currently experiencing any medical issues or discomfort? If yes, kindly describe 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/治疗的原因 Reason of Visit
*
个人心理 Personal Issues
个人情绪/压力 Personal Emotions/Stress
注意力/学习动机 Attention/Learning Motivation
社会适应(校园/职场) Social Adjustment (School/Workplace)
心理疾病 Abnormality/ Mental Health Disorder
人际关系 Interpersonal Relationship
伴侣关系 Relationship
婚姻咨询 Marriage
家庭关系 Family
健康问题 Health Issue
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 / 心理治疗吗?如果有,请填写治疗后的成果。
*
Have you experienced Psychotherapy before? If Yes, kindly share with us the outcome.
有 Yes
没有 No
之前的治疗效果:(如有)
Previous outcome: (if Yes)
您希望透过此次的疗程达到什么目的或成果?请列出您想要达到的目标。
*
What goals or results do you hope to achieve through this treatment? Kindly list down your desired goals in order of priority.
您期望的治疗项目(可选择多项)
*
Kindly choose your preferred type of therapy (Choose one or more)
心理咨询疗程 Consultation Session
催眠疗程 Hypnotherapy Session
心理评估 Psychological Assessment
心理治疗 (心理动力) Psychoanalysis Therapy
心理治疗 (认知行为治疗) Cognitive Behavioural Therapy
婚姻咨询 Marriage Therapy
家庭咨询 Family Therapy
事业咨询 Career Coaching
让心理治疗师建议 Preferred advice by professional
请选择诊疗的日子(可选择多项)
*
Choose your preferred day of appointment (Choose one or more)
星期一 Monday
星期二 Tuesday
星期三 Wednesday
星期四 Thursday
星期五 Friday
星期六 Saturday
星期日 Sunday
请选择诊疗的时间(可选择多项)
*
Choose your preferred time of appointment (Choose one or more)
早上 Morning
中午 Noon
下午 Afternoon
请选择治疗师的性别
*
Choose your preferred gender of Therapist
男 Male
女 Female
都可以 Both are fine
请选择语言
*
Choose Your Preferred Language
华文 Mandarin
英文 English
广东话 Cantonese
福建话 Hokkien
请问你想透过面对面或线上进行疗程?
*
what medium would you prefer to conduct the session?
面对面 Face to Face (Om Space Therapy Centre)
线上 Online (Online Zoom Meeting)
两个都可以 Both
治疗中心地点 Therapy Centre Location
*
Om Space Therapy Centre, Petaling Jaya
请选择疗程时长
*
Kindly select your preferred session duration
30 - 45 分钟 minutes
60 - 90 分钟 minutes
90 - 120 分钟 minutes (强力推荐 Strongly Recommended)
疗程同意书 Informed Consent Form
*
疗程同意书
我特此完全同意并接受 Om Space Therapy Centre 心理治疗师的治疗疗程与相关制度。
1. 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。
2. 我了解疗程不能替代医学治疗,也了解Om Space治疗师不开立药物处方,或给予任何药物治疗。
3. 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。
4. 我已尽我所能参加每次的疗程,并按照治疗师的要求准确提供了相关信息。
5. 我了解我在疗程中所说的事情会得到专业的保密,没有经过我的口头或书面同意,治疗师不会告知他人相关信息。我也了解专业保密的限制,如果我的谈话内容涉及自我伤害、伤害他人或涉及司法相关法令(儿童虐待、家庭暴力、性侵害等)时,我同意治疗师通知我的家人或相关机构,以便保护我及他人的安全。未满18岁的客户也同样会受到相关的隐私保护。
6. 我了解心理治疗师将根据我个人的心理情况与疗程进行情况并提供当下所需的专业疗程方案,或是疗程方案可能与我预约的疗程有所不同,我愿意接受心理治疗师的专业判断。
7. 我了解我所参与的疗程有时间限制,以确保Om Space Therapy Centre 的客户都可获得专业的预约安排。若我预约的疗程在无可避免的情况下超过时间限制,Om Space Therapy Centre将向我收取超时所需费用。
8. 我了解我可以随时询问关于评估或治疗的问题,包括评估或治疗的程序、疗程的场所与时间、费用及付款方式、保密的限制、治疗的效果与限制,以及社区资源等。
个人资料保护通知
1. 通过提交此表格,您特此同意Om Space Therapy Centre可以收集,获取,存储和处理您在此表格中提供的个人数据,以便接收来自Om Space Therapy Centre 的更新,服务,新闻,促销和营销邮件和/或资讯。您特此同意Om Space Therapy Centre存储和处理您的个人数据;或在马来西亚法律要求或出于法律目的的情况下,向相关政府机构或第三方单位披露您的个人数据。
2. 如果您希望请求访问或纠正您的个人数据或撤回/限制您的同意,您可以随时将您的请求发送给Om Space Therapy Centre。您的请求应受任何适用的法律限制、条件和合理期限的约束。
3. 另请注意,Om Space Therapy Centre可能会不时要求您提供最新的个人信息 。通过向我们提供您的个人信息或继续与Om Space Therapy Centre接洽,我们将视为您已同意处理此类数据。
4. 为免生疑问,个人数据包括《2010年个人数据保护法》中定义的所有数据,包括您在此表格中向Om Space Therapy Centre披露的所有数据。
退货和退款政策
1. 退货和退款政策适用于Om Space Therapy Centre以Om Space Sdn. Bhd品牌提供的所有产品和服务。
2. Om Space Therapy Centre已尽最大努力确保产品和服务得到正确履行。如果交付的产品和服务有任何差异,并且客户预想进行退货和退款,请在支付金额的五(5)天内联系我们的客户服务热线通知我们。
3. 在任何情况下,所有已完成的治疗疗程均不予退款。
4. Om Space Therapy Centre应保留预付款(第一笔支付款项),以扣除客户签订的的后续治疗与疗程。
5. 所有的疗程配套有效期为18个月,客户允许更换或转接其他治疗疗程配套,并根据不同的治疗疗程价格支付额外差价或费用。
6. 客户承认并同意所有签购的治疗疗程与配套不得要求退款,客户进一步同意,这是我们本协议的基本条款。
Informed Consent Form
I hereby fully agree to and accept the treatment provided by the practitioner and policies in Om Space Therapy Centre.
1. I understand that the results obtained through the treatment may be vary for each individual and no specific results can be guaranteed.
2. I understand that the treatment is not a substitute for medical treatment, and I understand that Om Space Therapy Centre’s practitioners do not prescribe medications or give any medications.
3. 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.
4. I have agreed to participate in each session to the best of my ability and accurately provided my background information as requested by the practitioner.
5. I understand that the information I provided during the treatment will be kept confidential professionally and the practitioner will not disclose the information to others without my oral or written consent. I am also aware of the limitations of professional confidentiality, if my information or conversation involves self-harm, harm to others, or involves a judicial-related statute (child abuse, domestic violence, sexual assault, etc.), I agree that the practitioner may notify my family or related agency in order to protect me and others. Clients who are under the age of 18 are also subject to the associated privacy protections.
6. I understand that the practitioner will provide the professional treatment needed according to my personal psychological condition and the progress of the treatment, or the treatment may be different from the treatment I booked. I am willing to accept the professional arrangement by the practitioner.
7. I understand that the treatments I participate in are time-limited to ensure that all Om Space Therapy Centre’s clients receive professional appointments equally. Om Space Therapy Centre may charge for overtime if my appointment is unavoidably over the time limit.
8. I understand that I can ask questions about the assessment or treatment at any time, including the procedure for the assessment or treatment, the location and timing of the treatment, the cost and payment method, the restrictions on confidentiality, the effects and limitations of the treatment, and the resources of the community.
Personal Data Protection Notice
1. By submitting this Form, you hereby agree that Om Space Therapy Centre may collect, obtain, store and process your personal data that you provide in this form for the purpose of receiving updates, services, news, promotional and marketing mails and/or materials from Om Space Therapy Centre. You hereby give your consent to Om Space Therapy Centre to store and process your Personal Data; or disclose your Personal data to the relevant governmental authorities or third parties where required by the law of Malaysia or for legal purposes.
2. If you wish to request access to or to rectify your Personal Data or withdraw/limit your consent, you may at any time send your request to Om Space Therapy Centre. Your request shall be subject to any applicable legal restrictions, conditions and a reasonable time period.
3. Please also note that from time to time, Om Space Therapy Centre may request for latest Personal Information from you. By providing us with your Personal Information or continuing to communicate with Om Space Therapy Centre, we shall regard that you have consented to the processing of such data.
4. For the avoidance of doubt, Personal Data includes all data defined within the Personal Data Protection Act 2010 including all data you had disclosed to Om Space Therapy Centre in this Form.
Return and Refund Policy
1. The Return and Refund policy shall be applicable to all products and services offered by Om Space Therapy Centre under the brand of Om Space Sdn. Bhd.
2. Om Space Therapy Centre shall use its best efforts to ensure that products and services are correctly fulfilled. Should there be any discrepancy of products and services delivered and the customer would proceed for return and refund, please notify us by contacting our Customer Service Careline within five (5) days upon paying the amount.
3. All fulfilled treatment sessions are strictly non-refundable in any kind of circumstances.
4. Om Space Therapy Centre shall keep the upfront payment (First payment) in deduction of subsequent treatment session that subscribed by the clients.
5. The session packages are valid for 18 months, clients are allowed to exchange or transfer the extra treatment sessions with other type of treatment sessions, additional fee may applied by following the particular treatment price list.
6. By signing up for any treatment session and/or package, the client acknowledges and agrees that client shall not claim any refund by strict compliance. The client further acknowledged that this is an essential term of this agreement which we rely on.
是 我同意 / Yes, I am aware and agree
签名 Signature
*
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Signature locked. Reset to sign again
Full Name per IC
IC No.
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)
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家长/监护人全名(如果客户是18岁以下)
Full Name per IC / ID of Parent / Guardian (if the client is under the age of 18)
By submitting the client intake form, I hereby agree with the
Informed Consent Form
Name
This field is for validation purposes and should be left unchanged.
Our Customer Support Team is here to answer your questions. Ask us anything!
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