Client Intake Form

OM SPACE THERAPY CENTRE

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Client Information Details

Full Name per IC / ID*

Preferred Name*

Prefix Preferred Name

IC / ID No.*

Date of Birth*

Gender*

Male

Female

Other

Phone Number*

Email*

Address*

Street Address Area City State Postcode Country

Occupation*

How do you get to know us?*

Other

Personal Medical History

Are you or your child (The Client) currently receiving treatment from a psychiatrist, counsellor or psychotherapist? If yes, please fill in the following information.*

Yes

Practitioner / Therapist Name: (If Yes)

Any diagnosis from the physician?

Yes

Kindly write the name of the diagnosis (Eg: depression, developmental delay, schizophrenia….)

When did the diagnosis begin? (Year)

Are you currently or have you ever received treatment?

Yes

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What kind of treatment is it?

Occupational Therapy

Speech-language Therapy

Physiotherapy

Sensory Integration Therapy

Other

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Other Type of Treatment

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When did you start treatment? (From which year to which year? Example: 2020 - 2022)

Are you or your child (The Client) currently taking any medications? If yes, kindly write down the name of the drug.*

Yes

Name of the medications: (If Yes)

Are you or your child (The Client) currently experiencing any medical issues or discomfort? If yes, kindly describe the medical condition.*

Yes

Medical Condition (Eg: Asthma / Heart Attack): (If Yes)

Therapy Session Details

Reason of Visit*

Choose one or more.

Personal Issues

Personal Emotions/Stress

Attention/Learning Motivation

Social Adjustment (School/Workplace)

Abnormality/ Mental Health Disorder

Interpersonal Relationship

Relationship

Marriage

Family

Health Issue

Career

Money and Wealth

Other

Other Reasons

Have you experienced Psychotherapy before? If Yes, kindly share with us the outcome.*

Yes

Previous Outcome: (If Yes)

What goals or results do you hope to achieve through this treatment?

Kindly choose your preferred type of therapy*

Choose one or more.

Omni Wellness Test

Consultation Session

Hypnotherapy Session

Psychotherapy Session

Clinical Psychological Assessment

Marriage Therapy

Family Therapy

Child Therapy

Career Coaching

Sound Therapy

Preferred advice by professional

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Choose your preferred day of appointment

Choose one or more.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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Choose your preferred time of appointment

Choose one or more

Morning

Noon

Afternoon

Choose your preferred gender of Therapist*

Male

Female

Both are fine

Choose Your Preferred Language*

Mandarin

English

Malay

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What way would you prefer to conduct the session?

Face to Face (Om Space Therapy Centre)

Online (Online Zoom Meeting)

Both are fine

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Therapy Centre Location

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Kindly select your preferred session duration

30 - 45 minutes

60 - 90 minutes

90 - 120 minutes (Strongly Recommended)

Emergency Contact

We require the contact information of your emergency contact for session record purposes. We will not contact your emergency contact unless necessary. The session process will be kept private and confidential.

Name

Phone Number

Relationship

Informed Consent Form*

Informed Consent Form
I hereby fully agree to and accept the treatment provided by the practitioner and policies in Om Space Therapy Centre.
1. I understand that the results obtained through the treatment may be vary for each individual and no specific results can be guaranteed.
2. I understand that the treatment is not a substitute for medical treatment, and I understand that Om Space Therapy Centre’s practitioners do not prescribe medications or give any medications.
3. I understand that in some circumstances it may be necessary for the practitioner to respectfully touch me on the hand, wrist, arms, shoulder or forehead as a means of helping me establish a beneficial state of relaxation, I hereby consent to such touching by the practitioner.
4. I have agreed to participate in each session to the best of my ability and accurately provided my background information as requested by the practitioner.
5. I understand that the information I provided during the treatment will be kept confidential professionally and the practitioner will not disclose the information to others without my oral or written consent. I am also aware of the limitations of professional confidentiality, if my information or conversation involves self-harm, harm to others, or involves a judicial-related statute (child abuse, domestic violence, sexual assault, etc.), I agree that the practitioner may notify my family or related agency in order to protect me and others. Clients who are under the age of 18 are also subject to the associated privacy protections.
6. I understand that the practitioner will provide the professional treatment needed according to my personal psychological condition and the progress of the treatment, or the treatment may be different from the treatment I booked. I am willing to accept the professional arrangement by the practitioner.
7. I understand that the treatments I participate in are time-limited to ensure that all Om Space Therapy Centre’s clients receive professional appointments equally. Om Space Therapy Centre may charge for overtime if my appointment is unavoidably over the time limit.
8. I understand that I can ask questions about the assessment or treatment at any time, including the procedure for the assessment or treatment, the location and timing of the treatment, the cost and payment method, the restrictions on confidentiality, the effects and limitations of the treatment, and the resources of the community.

Personal Data Protection Notice
1. By submitting this Form, you hereby agree that Om Space Therapy Centre may collect, obtain, store and process your personal data that you provide in this form for the purpose of receiving updates, services, news, promotional and marketing mails and/or materials from Om Space Therapy Centre. You hereby give your consent to Om Space Therapy Centre to store and process your Personal Data; or disclose your Personal data to the relevant governmental authorities or third parties where required by the law of Malaysia or for legal purposes.
2. If you wish to request access to or to rectify your Personal Data or withdraw/limit your consent, you may at any time send your request to Om Space Therapy Centre. Your request shall be subject to any applicable legal restrictions, conditions and a reasonable time period.
3. Please also note that from time to time, Om Space Therapy Centre may request for latest Personal Information from you. By providing us with your Personal Information or continuing to communicate with Om Space Therapy Centre, we shall regard that you have consented to the processing of such data.
4. For the avoidance of doubt, Personal Data includes all data defined within the Personal Data Protection Act 2010 including all data you had disclosed to Om Space Therapy Centre in this Form.

Return and Refund Policy
1. The Return and Refund policy shall be applicable to all products and services offered by Om Space Therapy Centre under the brand of Om Space Sdn. Bhd.
2. All fulfilled treatment sessions are strictly non-refundable in any kind of circumstances.
3. Om Space Therapy Centre shall keep the upfront payment (First payment) in deduction of subsequent treatment session that subscribed by the clients.
4. The session packages are valid for 12 months, clients are allowed to exchange or transfer the extra treatment sessions with other type of treatment sessions, additional fee may applied by following the particular treatment price list.
5. By signing up for any treatment session and/or package, the client acknowledges and agrees that client shall not claim any refund by strict compliance. The client further acknowledged that this is an essential term of this agreement which we rely on.

Yes, I am aware and agree

Signature*

Signature of Parent / Guardian

If the client is under the age of 18

Full Name per IC or ID of Parent / Guardian

If the client is under the age of 18

By submitting the client intake form, I hereby agree with the Informed Consent Form

Comments

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