Request for Psychological Services

Please be advised that the mental health session is not a substitute for an actual psychiatric consultation. The service aims to provide first aid information, and psychological advice. Please do not use the session to replace any necessary in-person consultation. In the event of a psychiatric emergency such as suicidal ideations, attempt, homicidal or self-injurious behavior, we would strongly suggest consult at the nearest Emergency room.

In compliance with the Data Privacy Act of 2012, our Mental Health Professionals will be asking you personal and medical information that we need to record for this consultation.  We assure that the information shared will be for the purpose of providing the best service in a timely manner. The shared information will solely be used by the clinic and will never be used for other purposes.


*for questions that do not apply to you, kindly write N/A

Have you consulted any mental health professional for the last ten (10) years?
Type of service requested:
Preferred mode of service: