新冠肺炎網上輔導預約申請 COVID-19 Online Counseling Appointment Request

感謝您使用我們的新冠肺炎網上輔導服務預約申請。我們的工作人員將會與您聯繫並確認您的預約。如果這是您的第一次輔導，請填寫此表格並電郵給我們。

Thank you for using our COVID-19 Online Counseling Appointment Request form. Please fill in the following information and our staff will contact you regarding your request. Please understand that your request is not confirmed until our staff contacts you and confirms the appointment. If this is your first appointment, please fill out this intake form and email to us prior to the appointment.

Last Name 姓 *

First Name 名 *

Phone Number 電話號碼 *

Text Available? 可以電訉留言?
Yes 可以No 不可以

Email 電郵

Therapist 輔導員

Preferred Language 首選語言

Is This Your First Appointment? 這會是你的第一次輔導嗎?
Yes 是No 否

Referred by 由誰轉介

First Preferred Date 首選日期

First Preferred Time 首選時間

Second Preferred Date 第二選擇日期

Second Preferred Time 第二選擇時間

Third Preferred Date 第三選擇日期

Third Preferred Time 第三選擇時間