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[Counseling Appointment Registration]
Name Date of Birth - -
(MM/DD/YY)
Gender male female Nationality
Language preferred
Country Born In
No.of year/months In Korea
Current Address
E-mail @
Home Phone - - Cellular Phone - -
Marital Status Single Married Divorced Engaged Separated Widowed
Type of Counseling Individual Couple Family Assessment
Counseling
Contents
Family/Couple
Couple Conflict Divorce Counseling ( before after ) In-Law Conflict
Parenting Marriage Domestic Violence
Communication Abuse Inter-cultural Marriage

Relationship
Interpersonal Issues Living Together sexual issues Physical Abuse
Sexual Abuse Homosexuality Dating
Emotional Abuse Premarital Conflict Bullying

Emotional
Depression Anger Anxiety Cultural Adjustment
Adjustment Phobia PTSD
Eating Problem Self-Worth Controlling Conflict

Others:( )
Preferred Counseling Time
Preferred Counselor? Yes No (Name of the counselor: )
Preferred time to be contacted Preferred method of contact Cellular Phone
Home Phone
Email
서울시 용산구 서빙고로 67 파크타워아파트 103동 402호 (우140-025) Tel : 02-2285-5915 (점심시간 12:00~13:00) Fax : 02-525-0618
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