Biodata Klien
Client Bio Form
Klien
Cornerstone
JAPC
Psikolog yang akan menangani [Appointed Psychologist]
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Allessandra Theresia, M.Psi., Psikolog
Aldo Rayendra, M.Psi., Psikolog
Ayutias Anggraini, M.Psi., Psikolog
Christella Ruslan, M.Psi., Psikolog
Christina Tedja, M.Psi., Psikolog
Clara Gia Shinta, S.Pd., M.A., Psikolog
Dicky Sugianto, M.Psi., Psikolog
Eunike Mutiara, Ph.D., Psikolog
Fransisca Febriana Sidjaja, Ph.D, Psikolog
Frida Sisca, M.Psi., Psikolog
Giavanny Panatra, M.Psi., Psikolog
Grace Indrawati, M.Psi., Psikolog
Gracia Indra, M.Psi., Psikolog
Gracia Stephanie, M.Psi., Psikolog
Helsa, M.Psi., Psikolog
Jessica A. Anna, M.Psi., Psikolog
Karel Karsten Himawan, Ph.D, Psikolog
Krishervina R. Lidiawati, M.Psi., Psikolog
Dr. Monty P. Satiadarma, MS/AT, MFCC, DCH, Psi.
Mentari Puteri, M.M., M.Psi., Psikolog
Sandra Handayani Sutanto, M.Psi., Psikolog
Dr. Teguh Lesmana, M.Psi., Psikolog
Vickie Januar, M.Psi., Psikolog
Wiwit P. Dewi, M.Psi., Psikolog
Yuliana Anggreany, M.Psi., Psikolog
Vinesia Febrianti, M.psi., Psikolog
Cornerstone Center
Tidak memiliki preferensi [No preference]
Mohon pilih yang paling sesuai [Please select one that applies]
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Saya mendaftar untuk diri sendiri [I am the client/user]
Saya mendaftar untuk orang lain [I make a registration on behalf of someone]
Nama Anda [Your Name]
First Name
Last Name
Hubungan dengan klien [Relationship to the client]
Orang tua [Parent]
Wali [Guardian]
Pasangan [Spouse]
Anak [Child]
Other
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Identitas Diri Klien
Client's Personal information
Nama Lengkap [Full Name]
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First Name
Last Name
Tanggal Lahir [Date of Birth]
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-
Day
-
Month
Year
Date
Jenis Kelamin [Sex]
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Laki-laki [Male]
Perempuan [Female]
Alamat [Address]
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nomor Handphone [Mobile]
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-
Area Code
Phone Number
Email
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example@example.com
Kewarganegaraan [Citizenship]
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Please Select
Indonesia [WNI]
Asing [Foreign / WNA]
Agama [Religious Affiliation]
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Islam [Islam]
Protestan [Protestant]
Katolik [Catolic]
Buddha [Buddhism]
Hindu [Hinduism]
Kongfucu [Confucious]
Ateis [Atheism]
Memilih untuk tidak menjawab [Prefer not to say]
Pendidikan terakhir [Education]
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Please Select
tidak ada [no formal education]
non-universitas [no university education]
Diploma [Diploma]
Sarjana [Bachelor]
Master [Master]
Doktor [Doctorate]
Anak ke / dari total bersaudara [birth order]
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Misal: anak ke 2 dari 3 bersaudara, maka tulis: 2 / 3 [Example: being the 2nd of 3 total siblings, please write: 2 / 3]
Status perkawinan [Marital status]
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belum menikah [never married]
menikah [married]
pisah [separated]
cerai [divorced]
cerai meninggal [widowed]
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Riwayat Pendidikan dan Pekerjaan
Educational and Work History
Pendidikan Terakhir
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Please Select
Tidak ada pendidikan formal [no formal education]
SD [elementary]
SMP [junior high school]
SMA [senior high school]
Diploma
S1 [Bachelor]
S2 [Masters]
S3 [Doctorate]
Spesialisasi bidang pendidikan [Field of expertise]
Pekerjaan saat ini [Current occupation]
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Riwayat Kesehatan Fisik & Psikologis
Medical & Psychological History
Apakah Anda pernah mendapat diagnosa psikologis? [Have you ever been formally diagnosed with any psychological disorders?]
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Ya [Yes]
Tidak [No]
Mohon deskripsikan diagnosa yang didapat, siapa yang mendiagnosa, dan kapan diagnosa diberikan. [Please describe what, by who, and when the diagnosis was established].
Apakah Anda pernah mengalami kecelakaan/trauma? [Have you ever had an accident/trauma?]
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Ya
Tidak
Jika pernah, mohon deskripsikan kecelakaan/trauma yang dialami? [If so, please describe the accident/trauma you experienced]
Apakah saat ini Anda sedang mengonsumsi obat-obatan tertentu? [Are you currently taking certain medications?]
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Ya [Yes]
Tidak [No]
Jika ya, sebutkan jenis atau nama obat tersebut [If yes, tell us the type or name of the medicine]
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Orang yang Dapat Dihubungi dalam Kondisi Darurat
Next of Kin Emergency Details
Nama Lengkap [Full Name]
*
First Name
Last Name
Jenis Kelamin [Sex]
*
Laki-laki [Male]
Perempuan [Female]
Hubungan dengan Anda [Relationship with you]
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orang tua [parents]
pasangan [spouse]
saudara kandung [siblings]
keluarga [family members]
anak [children]
teman [colleague]
Nomor Handphone [Mobile]
*
-
Area Code
Phone Number
Email
*
example@example.com
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Layanan yang Dibutuhkan Saat Ini
Required service
Apa layanan yang Anda perlukan? [What kind of service do you need?]
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Konseling & psikoterapi [counseling & psychotherapy]
Konseling pasangan/keluarga [couple/family counseling]
Adult Brief Evaluation
Tes IQ [IQ Profile]
Tes Minat Bakat [Career Pathway & Exploration]
Pemeriksaan Pasangan/Pra-nikah [Pre-marital Assessment & Counseling]
Terapi Neurofeedback [Neurofeedback Therapy]
Terapi Bermain [Play Therapy]
Terapi Seni [Art Therapy]
Terapi Musik [Music Therapy]
Other
Nama pasangan [Spouse's Name]
First Name
Last Name
Lama mengenal pasangan (dalam tahun) [years in relationship]
Kosongkan jika tidak relevan [leave empty if irrelevant]
Jenis layanan konseling yang diinginkan [Counseling format]
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Tatap muka [face-to-face]
Video/audio [Telecounseling]
Mohon ceritakan secara singkat apa permasalahan / kebutuhan Anda [Reasons for referral]
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Seberapa serius Anda merasa masalah tersebut mengganggu keseharian Anda? [To what extent do you think your daily life is affected by your problems?]
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1
2
3
4
5
6
7
8
9
10
Tidak terlalu mengganggu [not too much affected]
Sangat mengganggu [very much affected]
1 is Tidak terlalu mengganggu [not too much affected], 10 is Sangat mengganggu [very much affected]
Apa harapan Anda mengikuti sesi ini? [What is your expectation to the session?]
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Apakah Anda berharap agar sesi konseling Anda turut menyinggung nilai-nilai agama yang Anda yakini? [Do you expect to discuss your issues from your religious perspective?]
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Tidak [No]
Mungkin [Perhaps]
Ya [Yes]
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Foto Diri
ID Photo
Unggah foto diri di sini [Upload your self photo here]
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Lembar Persetujuan [Informed Consent]
Mohon pelajari syarat dan ketentuan untuk layanan kami dan berikan persetujuan di bawah. [Please peruse the terms and conditions for our service and indicate your agreement below].
Silakan tanda tangan di sini jika Anda telah setuju dengan semua jawaban Anda [Please sign here should you agree with all your above responses]
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