CLIENT INTAKE FORM

STATEMENT OF POLICIES AND PROCEDURES

The Contract of Service

The services described in this statement are provided by Eve Lim Wei Jia (herein referred to as
“therapist”), who is a trainee counsellor under clinical supervision. Therefore, this contract is
between Eve Lim Wei Jia and you (herein referred to as “client”).

About Therapy
Therapy involves a collaboration between the therapist and the client to achieve the client’s
goals for personal, professional, or relationship development. The therapist is equipped with
specialised skills and tools to support the client by:
•identifying patterns in thoughts, emotions, and behaviours,
•providing alternative interpretations of events,
•stimulating thinking through purposeful questions, and
•facilitating the formulation of strategies to resolve problems.
The client’s openness and honesty when discussing concerns and challenges can facilitate the
therapy progress more effectively. As the client is believed to be the best judge of their own
interests and needs, the therapist does not usually offer personal opinions, direct advice, or
solutions to the client. The aim of therapy is to empower the client to take ownership of their well-
considered decisions and choices.

Potential Benefits and Risks of Therapy

It is helpful to be aware of the benefits of therapy and some common setbacks that may
develop in the course of examining and working through areas of concern.

Potential benefits can include:

•better understanding of self;
•accomplishment of realistic goals;
•improvements in interpersonal relationships;
•enhancement of academic or work performance;
•positive developments in self-esteem, assertiveness, and overall mood;
•development of skills and techniques to independently resolve problems.

Potential risks can include:

•confrontations with uncomfortable truths about the self;
•changes in interpersonal relationships that may occur as a result of differences in
perspectives and behaviours;
•experiences of emotional discomfort when remembering past events, dealing with
unresolved issues, or realising the severity of an issue.
CARA CARA Statement of policies and procedures Page 2

Therapeutic Services
The therapist offers therapy for individuals within the limits of the therapist’s capabilities.
While anything can be discussed in therapy, examples of topics include:

Motivation Sexuality Anger Loneliness

Procrastination Self-esteem Anxiety Grief and loss
Career development Aging concerns Depression Romantic relationship
Work or academic stress Adjustment issues Sleep difficulties Family or peer conflict

The duration of each therapy session is approximately 60 minutes. Sessions are usually
scheduled once per week, but the therapist or client may schedule sessions more or less
frequently according to the client’s therapeutic needs.

The client is free to discontinue therapy at any time, although it is advisable to discuss the
reasons for discontinuation with the therapist prior to acting on the decision. If the client is at
any time dissatisfied with the services provided by the therapist, they are encouraged to
discuss with the therapist to resolve said grievances. In the event that the dissatisfaction
persists, the client may proceed to discontinue therapy after notifying the therapist.

The therapist may initiate termination of therapy when the client has achieved therapy goals or
been referred to another provider.

Limits of the Therapeutic Relationship

The relationship between the therapist and the client will be strictly professional and limited to
therapeutic services, as governed by ethical guidelines adhered to by the therapist.

As such, it is improper for the therapist to provide therapeutic services to individuals with the
following relations to the therapist:
•Family members, relatives, friends, or relatives of friends;
•Current business engagements besides the therapeutic relationship (e.g., employer or
employee, lending or borrowing, trading or bartering services or goods for therapy);
•Any kind of current or former romantic or sexual relationship.

All of the following limits apply throughout the therapeutic relationship and maintain even after
therapy has been terminated:
•Contact between the client and the therapist will be limited to the therapy office. Phone
calls, text messages, or emails will pertain only to appointment scheduling in order to
ensure professional boundaries and protect client confidentiality. Exceptions to this rule
may occur should there be any crisis involving the client’s safety;
•The therapist may not accept nor send any invitations to participate in personal online
social networks (e.g., Facebook, Instagram, Twitter, etc.) with the client;
•In order to keep the client’s identity confidential, the therapist may ignore the client when
encountered in a public place and may decline invitations to gatherings;
•The therapist may not accept any gifts or tokens of appreciation worth more than RM30
from the client.
CARA CARA Statement of policies and procedures Page 3

Limits of Services
The therapist may be unable to provide therapy or may deny further therapy to an individual in
the following situations:
•Clinical considerations (e.g., beyond the therapist’s capacity to effectively help);
•Ethical considerations (e.g., dual relationship issues, inappropriate conduct, etc.);
•Involvement in legal proceedings (e.g., court-ordered, forensics, divorce, etc.);
•Abuse or misuse of services in any manner (e.g., non-compliance with treatment, frequent
missed appointments, etc.);

The therapist does not diagnose any illness, prescribe any psychotropics or medications, or
monitor client’s usage of psychotropics or medications.

Referrals
If services have been denied to the individual, or if the therapist or the client determines that
the client’s needs are best met by alternative sources of care, the therapist may be able to
provide a reasonable number of alternatives or referrals to appropriate services that may be
available to assist the client.

In cases where any exchange of information is necessary between the therapist and another
professional (e.g., medical doctor, insurance provider, etc.), the client must provide written
consent to the therapist before information pertaining to the client can be shared.

Legal Proceedings
The therapist will not be involved with legal proceedings instigated by the client (e.g., divorce
proceedings, custody proceedings, etc.). However, should the therapist be subpoenaed by the
court to testify, the client will have to pay the fee of RM300 per hour to the therapist for
preparation and testifying time (including depositions).

Confidentiality
The therapist will maintain confidential, any and all information obtained during the course of
therapy with the client. However, some exclusions to confidentiality exists. These include, but
are not limited to:
•when the client is determined to be a danger to themselves or others;
•when the therapist perceives there may be child or elder abuse and/or neglect;
•when the therapist is mandated by law to report any information obtained during
the course of service.

Should any of the above take effect, every effort will be made by the therapist to inform the
client of said breach of confidentiality and the steps that will be taken henceforth.

The therapist may also use information obtained during therapy for the purposes of
administration, clinical supervision, or clinical training.
CARA CARA Statement of policies and procedures Page 4

Data Management
Data describing the client’s contact information, personal health information, scheduling of or
attendance at appointments, content of sessions, and therapy progress are stored
electronically. While using any electronic-based format carries inherent security risks that
cannot be 100 per cent prevented, the service platforms, encryption technology, operation,
and processes are utilised with the client’s security and privacy in mind. The data are
password protected and best practices to prevent unauthorised access, use, and disclosure
are applied. The data will be stored for seven years and cleared thereafter. The therapist will
not release the data without the client’s written consent, with the exception of circumstances
described in the Confidentiality section above.

Client Conduct and Commitments

The client confirms that they are legally able to consent to receiving the therapist’s services, or
have the consent of a parent or guardian, and that they are legally able to enter into a contract.

The client confirms that all information that they provided in or through the online appointment
booking site, online video conferencing platform, electronic signature platform, e-mail
providers, and text messaging platform used in relation to the therapist’s services (collectively,
“Electronic Platforms”), and the information that they will provide in or through the Electronic
Platforms in the future, is accurate, true, current, and complete. Furthermore, the client agrees
that during the term of the Contract of Service, the client will make sure to maintain and
update this information so it will continue to be accurate, current, and complete.

The client commits to not using the Electronic Platforms for posting, sending, or delivering of
either of the following: (a) unsolicited email and/or advertisement of promotion of goods and
services; (b) malicious software or code; (c) unlawful, harassing, privacy invading, abusive,
threatening, vulgar, obscene, racist, or potentially harmful content; (d) any content which may
constitute, cause, or encourage a criminal action or violate any applicable law.

The client is responsible for maintaining the confidentiality of their passwords, any other
security information, and personal information related to the Electronic Platforms. The client is
advised to change their passwords frequently and to take extra care in safeguarding their
passwords. The client must notify the therapist immediately of any unauthorised use of or any
other concern for breach of security to the Electronic Platforms.

The therapist will not be liable for any loss or damage incurred as a result of unauthorised use
of or access to the Electronic Platforms, either with or without the client’s consent and/or
knowledge. The client will indemnify, defend, and hold the therapist harmless from and against
any and all claims, losses, causes of action, demands, liabilities, costs or expenses (including,
but not limited to, litigation and reasonable legal fees and expenses) arising out of or relating
to any of the following: (a) client’s access to or use of the Electronic Platforms; (b) any actions
made with the client’s data on the Electronic Platforms whether by the client or someone else;
(c) client’s violation of any of the provisions within this Statement of Policies and Procedures;
(d) non-payment for any of the therapist’s services; (e) client’s violation of any third party right,
including, without limitation, any intellectual property right, confidentiality, publicity, property or
privacy right. This clause shall survive termination of the Contract of Service.
CARA CARA Statement of policies and procedures Page 5

Appointments
In-person therapy sessions will be attended to within the premises of office space. Online
therapy sessions will be conducted using an online video conferencing platform. In the event of
poor internet connectivity that prevents optimal video call quality for online sessions, the
therapist in agreement with the client may either resume the video call at a time that is
convenient for both parties once internet connectivity improves or use online audio call for the
remaining time of the session.

All sessions are by appointment only. Appointments can be booked according to the therapist’s
availability via an online appointment booking site. All sessions will start and end according to the
stipulated time. Depending on the therapist’s availability, extensions to the pre-determined
duration of the session may be made with a pro-rated fee at a half-hourly rate.

Fees
Advance payment of the session fee is required to secure an appointment. Booking will be
cancelled if payment is not received within 1 day from the time of booking. An appointment
will be secured with the following steps:
[Link] client makes payment via QR Pay or instant transfer to the therapist’s bank account,
as instructed in the online appointment booking site.
[Link] client uploads proof of payment for the therapist to verify.

All bank charges are to be borne by the client for any payment transaction, including
international transfers.

Session fee may be forfeited in the following situations:

•Reschedule or cancel less than 48 hours from the scheduled session time. The session will
be considered as a no-show.
•No-show or late arrival (without prior notice) more than 20 minutes from the scheduled time.
•Single session not utilised within 6 months of the date of purchase.
In an emergency circumstance that makes attendance impossible (e.g., medical condition,
natural disasters, etc.), the session can be rescheduled with no additional charges.

Refund for session cancellation can be obtained by making a written request to the therapist
at least 48 hours prior to the scheduled session. Failure to do so, no refund will be entertained.

Important note: The fees and policies described in this Statement of Policies and Procedures
are subject to change without prior notice.
CARA CARA Statement of policies and procedures Page 6

CONSENT TO THERAPY

I have had an opportunity to read this Statement of Policies and Procedures, ask any
questions regarding it, and I agree with all the provisions specified within the statement.
I understand that if I have any reservations, I should not sign this statement.

I understand that by agreeing (or on behalf of minor(s) or vulnerable person(s) under my care)
to participate in therapy with the therapist means that:
•I am aware of the potential benefits and risks of therapy;
•I accept the limits applicable to services, confidentiality, and the therapeutic relationship;
•I know that I must pay the agreed fee for the services rendered by the therapist;
•I understand that I must provide a 48-hour advance notice to cancel or reschedule my
appointment, otherwise I may be charged for the missed session;
•I am aware that I may discontinue therapy with the therapist at any time;
•I understand that no promises have been made to me as to the outcome of therapy or of
any procedures provided by the therapist;
•I expect that the therapist will receive clinical supervision, and referral to appropriate
services will be made when necessary.

My signature below proves that I accept, understand, and agree with all the above statements.

[[s|0
Client’s Signature
]] [[s|1
Therapist’s Signature
]]
[[t|0 ]] Eve Lim Wei Jia
Client’s Full Name Therapist

Date:
Date:
]] [[d|1|p:0 ]]
[[d|1|p:0

]] [[s|1
Parent / Guardian’s Signature
]]
Date:

For office use only.

Client Code:
 CLIENT INFORMATION FORM

Full Name: [[ ]]
Preferred Name: [ ]] Date of Birth: ]]
NRIC / Passport No.: [ ]] Age: [ ]]
Gender: [[ ]] Preferred Pronouns: [[ ]]
Current Residential Address:

[[t|0 [[t|0 ]]
Permanent Residential Address (Leave blank if same as current address): ]]
[[t|0|r:0
[[t|0|r:0 ]]
]]
Mobile No.: ]]
Email: ]]
Preferred Language(s): ]]

Current Occupation: ]]
Employment Length: ]]
Relationship Status (e.g., Single, Serious Dating, Open, Married, Widowed, etc.):
]]
[[t|0 ]] No. of Children:

In case of an emergency, the therapist will notify this contact person on your behalf:
Emergency Contact Name:[[t|0 ]]
Relationship to You: ]]
Mobile No.: [[t|0 ]]
Email: ]]

How did you find out about this service?[[t|0 ]]

____ ______________

For clients under age 18:

Parent / Guardian Name: [[t|0|r:0 ]]
Relationship to Client: [[t|0|r:0 ]]
NRIC / Passport No.: [[t|0|r:0 ]]
Mobile No.: [[t|0|r:0 ]]
Email: [[t|0|r:0 ]]
CARA CARA Client Information Form Page 2

Rate how you have experienced the following in the past 2 weeks:

0 = “Not at all”, 1 = “Mild”, 2 = “Moderate”, 3 = “Severe”

Feel sad, blue, or depressed [[t|0 ]]

Crying spells [[t|0 ]]
Feel guilty [[t|0 ]]
Feelings of hopelessness [[t|0 ]]
Loss of interest or enjoyment in activities [[t|0 ]]
Feel tired a lot
[[t|0 ]]
Difficulty concentrating
[[t|0 ]]
Memory problems
[[t|0 ]]
Feel anxious, nervous, or panicky
[[t|0 ]]
Deathly afraid of something (e.g., heights, etc.)
Seen or heard things that might not be there
[[t|0 ]]
Think or believe things that others say are not possible or real
[[t|0 ]]
Do certain things more than other people (e.g., check locks, clean)
[[t|0 ]]
Feel unusually good or do very impulsive things
[[t|0 ]]
Avoid places or situations
Sexual concerns
Headaches
Heart pounding / racing
[[t|0 ]]
Hot / cold sweats
[[t|0 ]]
Dizzy / lightheaded [[t|0 ]]
Stomachache [[t|0 ]]
Vomiting [[t|0 ]]
Diarrhea
Shortness of breath or difficulty breathing [[t|0 ]]
Changes in sleep patterns [[t|0 ]]
[[t|0 ]]
Difficulty falling asleep
Difficulty staying asleep
Difficulty staying awake
Frequent nightmares
Changes in weight or appetite
Increase
Decrease
Thought about hurting / killing another person [[t|0 ]]
Thought about physically hurting yourself [[t|0 ]]
Thought about killing yourself [[t|0 ]]
Have physically hurt yourself (Mark / if Yes)
Have a plan to kill yourself (Mark / if Yes)
Have attempted to kill yourself (Mark / if Yes)
CARA CARA Client Information Form Page 3

If married or in a relationship, indicate if any of the following are of concern:

(Mark / if Yes)

Frequent arguments Poor sexual relationship [[t|0|r:0]]

Unresolved issues Physical abuse [[t|0|r:0]]
Poor communication Infidelity / unfaithfulness
[[t|0|r:0]]

List your immediate family members. If applicable, list other persons living with you too:

Relationship to you Age Living with you

[[t|0|r:0 ]] [[t|0|r:0 ]]

Indicate if anyone in your family (excluding yourself) has experienced:

(Mark / if Yes)

Anxiety [[t|0|r:0]] Drug use [[t|0|r:0

Depression Prison
[[t|0|r:0]] ]]
Divorce Attempted or completed suicide
[[t|0|r:0]] [[t|0|r:0
Abuse Taken medication for mental health reasons
Drinking problems [[t|0|r:0]] Hospitalised for mental health reasons ]]
[[t|0|r:0]] [[t|0|r:0
]]
Did you lose a parent through death during childhood?(Mark / if Yes) [[t|0|r:0
Were you abused in any way as a child?(Mark / if Yes) ]]
Have you ever experienced an unexpected or traumatic event?(Mark / if Yes) [[t|0|r:0
]]
Do you have any current concerns about your physical safety?(Mark / if Yes)

Describe any spiritual / religious beliefs, practices, or views that are important to you:
[

Describe any aspects of your culture, ethnicity, sexual orientation, or gender identity
that you would like your therapist to be aware of:
[[t|0|r:0 ]]
CARA CARA Client Information Form Page 4

Indicate if you have ever utilised services from the following mental health practitioners:
(Mark / if Yes)

Clinical psychologist[[t|0|r:0]]Counsellor (Individual / Couple / Family / [[t|0|r:0]]

Pastoral / Addiction / Group)
Psychiatrist [[t|0|r:0]]

Have you ever been hospitalised for mental health reasons?(Mark / if Yes)

List any psychological or psychiatric conditions that you have been diagnosed with:
(e.g., major depressive disorder, obsessive-compulsive disorder, schizophrenia)

Conditions Year of Diagnosis

[[t|0|r: ]] [[t|0|r:0 ]]
0 ]][[t|0|r:0 ]]
[[t|0|r:
0 any health conditions or disabilities that you have been diagnosed with:
List
(e.g., surgery, high blood pressure, diabetes, mobility limitation, learning disability)
Conditions Year of Diagnosis

[[t|0|r: ]] [[t|0|r:0 ]]
0 ]][[t|0|r:0 ]]
[[t|0|r:
0 any prescription drugs / over-the-counter medication you are currently taking:
List

Name / Type of Medication Dosage

[[t|0|r: ]] [[t|0|r:0 ]]
0 ]][[t|0|r:0 ]]
[[t|0|r:
0
Indicate your use of the following substances:
- Frequency (e.g., daily / weekly / occasionally / in the past / not at all)
- Amount (e.g., number of cups / glasses / sticks / grams)
Caffeine Alcohol Tobacco Marijuana Street Drugs

[[t|0 ]] ]] ]] ]] [[t|0 ]]

List the reason(s) you are seeking therapy or concerns you want to work on in therapy: