Title*
MrMrsMsOther

Name*

Surname*

First Name*

Personal Telephone Number*

Contact Specification*
Leave messageNo messageOthers

Personal Email*

Counselling service requested*
Individual CounsellingCouple CounsellingFamily Counselling

Appointment Preference*
Mon - Fri (morning & afternoon)Mon - Fri (evening)Weekend (morning)Weekend (afternoon)Others

Fee Preference*
Counselling Intern (HK$200)Certified Counsellors (HK$500-800)Senior Counsellor & Family Therapist (HK$1500)

PERSONAL INFORMATION COLLECTION STATEMENT

The personal data provided on this form will be used by the Institute for membership registration and administration purposes only (and for sending to you promotional materials of ISS & ISSFI programmes and activities if you have not opted out by checking the tick box). Under the provision of the Personal Data (Privacy) Ordinance, applicants have the right to request access to and make correction of their personal data. Applicants should make such requests by email to issfi@isshk.org. Please refer to our privacy policy for details.

• Tel: (852) 2834 6863
• WhatsApp: (852) 6360 2212
• Email: issfi@isshk.org
• Website: www.issfi.org / www.isshk.org
• Address: ISS-HK, 6/F, Southorn Centre, 130 Hennessy Road, Wanchai, Hong Kong
• Service hours: Mon 9pm-1pm / 2pm-6pm; Tue to Fri 9pm-1pm / 2pm-5:45pm