Consent Form PERSONAL INFORMATION Date: Name*: Address: E-mail*: Mobile Phone*: Home Phone*: Occupation: Employer: Date of Birth*: NRIC No*.: Marital Status: SingleMarriedDivorcedWidowed Previous Medical / Psychiatric History: Presenting Symptom(s): Goal of Therapy: IN CASE OF EMERGENCY Name*: Contact Number*: Relationship To Client*: CONSENT TO THERAPY I do hereby seek and consent to take part in the treatment by the therapist at Mind Your Health. I understand that developing a treatment plan with the therapist and regularly reviewing our work towards meeting the treatment goals are in my best interest. I agree to play active role in this process. I give my consent for the therapist to contact physician(s) if necessary for information related to my clinical conditions. I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment. If I do not cancel and do not show up, I may be charged for that appointment in total. By proceeding, I understand and agree to all of the statements above.