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[Counseling Appointment Registration]
Name Date of Birth - -
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
Couple Conflict Divorce Counseling ( before after ) In-Law Conflict
Parenting Marriage Domestic Violence
Communication Abuse Inter-cultural Marriage

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

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
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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