Make an Appointment – General Enquiry/Appointment Form

All information collected through this form will be treated as confidential.

By filling up this form, it will help us expedite the process to meet your request.

You will be contacted within 3 working days. Our Intake Officer will talk with you further about the appointment, fees and other administrative matters that you have queries about.

Type of Counselling Needed*
Enquirer's Particulars
This form is for Individual enquiries
Please select this if you are also the client
- I am also the Client
Name*
Gender*
Local Contact Number*
Email*
Source of Referral (How did you come to know about our services?)*
Source of Referral (Others, please specify)*
Enquirer's Particulars
This form is for Couple/Family enquiries.
Please select this if you are also the client
- I am also a client
Name*
Nationality*
For Foreigners, please specify your nationality*
Country
Local Contact Number*
Email*
Gender*
Date of Birth*
DD slash MM slash YYYY
Marital Status*
Year of Marriage*
No. of Children & their Ages*
Source of Referral (How did you come to know about our services?)*
Source of Referral (Others, please specify)*
Client's Particulars
Name*
Relationship to Enquirer*
Relationship to Enquirer (Others, please specify)*
Nationality*
For Foreigners, please specify your nationality.*
Country
Local Contact Number
Email
Gender
Date of Birth*
DD slash MM slash YYYY
Marital Status
Year of Marriage
No. of Children & their Ages
Is your place of employment a member of National Council of Social Service (NCSS)?*
Client's Designation*
Total gross monthly income (inclusive of all freelance/part-time/contractual employment)*
Housing Type*
Reason for Contact*
What kind of Personal issue/s are you experiencing?*
How long have you been feeling this way?*
What kind of addiction?*
What kind of Relationship issue/s are you experiencing?*
Is there a third party involved?*
What kind of Work-Related issue/s are you experiencing?*
Note: First appointment will be fixed during office hours ONLY.
Preferred Language*
Preferred Language (Others, please specify)*
Preferred Day*

AM (9am – 12pm)

PM (12pm – 6pm)

EVE (Wed & Thu 6pm – 9pm)

Sat AM (9am – 12pm)
Have you been to a Counselling Centre/FSC/another Counsellor?*
Message – Please briefly describe the challenge that you are seeking our service for.*
Additional Information
Nationality*
For Foreigners, please specify your nationality.*
Country
Date of Birth*
DD slash MM slash YYYY
Marital Status*
Year of Marriage*
No. of Children & their Ages*
Is your place of employment a member of National Council of Social Service (NCSS)?*
Client's Designation*
Total gross monthly income (inclusive of all freelance/part-time/contractual employment)*
Housing Type*
Designation*
Reason for Contact*
What kind of Relationship issue/s are you experiencing?*
Is there a third party involved?*
What kind of Personal issue/s are you experiencing?*
How long have you been feeling this way?*
What kind of addiction?*
What kind of Work-Related issue/s are you experiencing?*
Note: First appointment will be fixed during office hours ONLY.
Preferred Language*
Preferred Day*

AM (9am – 12pm)

PM (12pm – 6pm)

EVE (Wed & Thu 6pm – 9pm)

Sat AM (9am – 12pm)
Preferred Language (Others, please specify)*
Have you been to a Counselling Centre/FSC/another Counsellor?*
Message – Please briefly describe the challenge that you are seeking our service for.*
Declaration*
- By submitting my personal data here, I hereby agree and consent that Eagles Mediation & Counselling Centre (EMCC) may collect, store and process my personal data that I have provided for the purpose of administration.
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Phone
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Make an Appointment – General Enquiry/Appointment Form

Enquirer's Particulars

Enquirer's Particulars

Client's Particulars

Additional Information

For Processing

For Approval

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