You&Me Psychological and Counseling Services

First Name

Last Name

Address in Korea

Cellular Phone Number

Gender

Male

Female

Others

E-mail

Birthday

Country of Origin

I am interested in receiving...

Please let us know what you hope to address in therapy. (example. depression, anxiety, adjustment, identity issues)

I prefer to schedule an appointment during ___ of the day. Please choose all available hours.

Morning (10am-12pm)

Afternoon (1pm-4pm)

Evening (5pm-8pm)

I prefer to see ______ level of therapist. The fee may vary depending on the language, duration of session, and age(minor).

Ph.D. Licensed Psychologist (180,000KRW-300,000KRW)

Master's Counselor (100,000KRW-300,000KRW)

Resident (80,000KRW-150,000KRW)

[Currently Unavailable] Intern (50,000KRW-100,000KRW)

I have received therapy in the past.

Yes

No

Not Sure

If you have a foreign health insurance plan, please write the name of the policy.

Additional Documents (If applicable): Insurance Card, Referral Letter, Enrollment Verification Letter, Student ID, etc.

How did you find out about us?

* At least 24 hour-notice is required for cancellation of the scheduled session or you will be charged a penalty fee for the missed appointment.

I hereby acknowledged that I read the YPCS's 24-hour cancellation policy.

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