Strictly Confidential

Member Intake Form

To match you with the most suitable psychologist, please complete all fields below. All information is completely confidential, protected under professional confidentiality standards, and will only be used to arrange your counselling service.

🔒 All information you provide is encrypted and kept strictly confidential. We will never share your personal information with any third party without your explicit consent.

Personal Information *

What issues would you like to work on?

Select all that apply

Session Preferences

If you have a specific therapist in mind (e.g. from your AI matching results), please enter their name. We will do our best to accommodate your request, subject to the therapist's availability and clinical suitability.

Knowing your personality type helps us match you with a psychologist whose style complements yours. Select "Not sure" if you don't know.

Clinical Background

Emergency Contact

⚠️ In rare situations where our clinical team assesses there is an imminent risk to your safety, we may need to contact your emergency contact. This information will only be used when necessary and is kept strictly confidential.

Additional Information