TOUCH Counselling Form

Please complete the form below and our staff will get in touch with you.

Please fill up the following counselling form and we will be in touch with you shortly.

Kindly note that each counselling session is with a chargeable fee of $100 - $120*. A surcharge of $20 applies for appointments outside office hours. Office hours are from Monday to Friday, 9am - 6pm.

*Effective from January 2024, the rates stated are not inclusive of GST.

Salutation

Full Name

Contact No.

E-mail

Date of Birth (DD/MM/YY)

Gender

Marital Status

No. of Children

Monthly Per Capita Household Income (PCHI)*

(PCHI > $2,800)

($2,000 < PCHI ≤ $2,800)

($1,900 < PCHI ≤ $2,000)

($1,200 < PCHI ≤ $1,900)

($800 < PCHI ≤ $1,200)

(PCHI ≤ $800)

*Monthly PCHI is computed as the total gross household monthly income divided by the total number of family members living together in the household. Gross monthly household income includes basic employment income, trade/self-employed income, overtime pay, allowances, cash awards, commissions, and bonuses.

Preferred Language for Counselling

What support do you require?

Is the support for yourself/others?

Self

Others

If OTHERS, please specify your relationship with the person

New code

Please type the code above

By submitting this form, I understand that the information provided above will only be used to maintain or enhance the relationship with TOUCH. TOUCH is committed to maintain the confidentiality of the information provided by me and undertakes to not divulge to any third party without my prior consent. I have read and understood the TOUCH Privacy Policy as stated on https://www.touch.org.sg/privacy-policy