Comarigoto Konsultasi

Tolong mengisi item-item dibawah ini sebanyak mungkin untuk memfasilitasi penerimaan konsultasi.

■Nama panggilan
■Jenis kelamin: Pria Wanita Selain itu
■Usia/umur
■Alamat tempat tinggal

【Notes on use】
・The consultation is provided by a team. If necessary, we may obtain consent and share the details of the consultation with a support organization.
・In order to improve a quality of consultation, we may be ask for questionnaire after the consultation.
・We prohibit you to release, transfer, and make a copy of what is written.
・The content of the consultation may be used for the statistical purposes without identifying individuals.
・When we determine that there is a life-threatening danger, we may contact the relevant organizations such as police to ensure safety.