CLIENT INTAKE

Client Intake Form

Please complete this form after the initial call and confirmation of a formal session.

CONFIDENTIAL INFORMATION

Complete at your own pace

You do not need to describe every experience in detail. You may write “prefer not to answer” unless information is required for safety assessment.

Confidential information

This form collects information before a first formal session.

Fields marked * are required

1. Basic Information

Legal or preferred name *How would you like Cindy to address you? *Year of birth or age *Current country or region *Current city *Time zone *Email *Phone or WeChat *

Preferred counselling language *

Mandarin Chinese English Other

2. Emergency Contact

Used only when necessary in a serious and urgent safety situation.

Emergency contact name *Relationship to you *Phone *Country or region *

3. Counselling NeedsWhat would you most like to discuss or receive help with? *Approximately how long has this concern been present? *

Have you previously received counselling or other mental health services? *

No Yes

If you wish, briefly explain

Are you currently receiving counselling, psychiatric or other mental health services? *

No Yes

If you wish, briefly explain

4. Safety & Health

Have you recently experienced strong thoughts, plans or actions related to harming yourself, suicide or harming someone else? *

No Yes

Answering “Yes” does not automatically prevent service. Cindy may contact you before the session to understand current safety and whether online counselling is appropriate.

If you wish, briefly explain

Is there important physical health, mental health, medication or recent life-event information Cindy should know before the first session?

5. Online Counselling & Policy Acknowledgements

I understand Yuexin provides scheduled online counselling and is not a 24-hour crisis service. * I will participate from a quiet, private and safe setting where possible. * In an urgent safety situation, I agree to provide my actual location so appropriate action can be taken. * I understand Cindy is based in Canada and information may be received, processed or stored outside my location. * I have read the Informed Consent information. * I have read the Privacy and Personal Information Policy. * I have read the Booking and Payment Policy. * I confirm this information is provided knowingly and voluntarily. *

Electronic signature (type your name) *Date *

Informed Consent Privacy Policy Booking & Payment Policy