Full Consultation Intake Form

Welcome — I’m glad you’re here!
This form is intended to help me understand what you hope to achieve through therapy.

Basic Information

Last Name

First Name

Preferred Name

Preferred Language

Phone Number

Country / Region

Address

City & Postal Code

Date of Birth Format: mm/dd/yyyy

Workplace

Emergency Contact & Phone

Therapy Information

Have you received therapy before? If yes, when did it start and end, and what was the experience like?

What brings you to therapy at this time?

Your goals and expectations for therapy

Are you currently taking medication? Names, dosage, and how long have you been taking them?

Have you ever engaged in self-harm?

Anything else you would like me to know?

Additional Information

I hope the above information helps you understand my credentials and what you can expect from therapy. You may email me or ask during our meeting.

What are your qualifications?

I am a clinical psychotherapist trained at The Hong Kong Polytechnic University with over 8 years and 4,500 hours of experience, certified by the Chinese National Health Commission and registered with the Hong Kong Professional Counselling Association.

How long is each session?

Each session lasts 50 minutes.

Is what I share confidential?

All information is confidential unless required by law or safety concerns. Exceptions include abuse reporting, court orders, and risk of harm. In couples therapy, individual communication is not confidential from the partner.

What is the fee?

RMB 800 per 50-minute session. Total cost depends on number of sessions.

Do you take insurance?

Private sessions are not in-network; some sessions at Shenzhen Vista Clinic may be reimbursable. Monthly receipts can be provided.

Cancellation policy

Full fee is charged if cancelled less than 24 hours in advance.

Important

You must commit not to harm yourself or others during therapy; otherwise immediate psychiatric care is required.

How to Contact You

Email: xiaoquan.deng@connect.polyu.hk
Work WeChat: gzhuixiang1
For emergencies call 110.

I have read, understood, and agreed to the above policies and financial terms.

Agreement & Signature

I have read, understood, and agreed to the above policies and financial terms.

First Name

Last Name

Signature