Relate Malaysia

[email protected]
130, Jalan Limau Purut, Bangsar Park,
59000 Kuala Lumpur
(Number 0322013583 is not in service)
0322013583

1. Intake Questionnaire Feb 2023

Please answer all questions honestly and to the best of your knowledge. There are
no wrong answers. Your answers will help us to have a clearer idea about what's
going on.

Malaysian IC (only enter numbers): 970125135046

Race/Ethnicity: Malay

Gender: Female

Religion: Islam

Current address of residence: No. 8B Jalan Apollo 96000 Sibu Sarawak

Complaint

What is your major complaint?:Feeling unmotivated and scared to start something once the anxiousness on a
given thought starts, struggling to open up and make genuine connections with
people, finding it hard to trust a person after a betrayal

Aggravating Factors for current problem (what makes it worse?):uncertainties about a lot of things

Relieving Factors for current problem (what makes it better?):talking about it with my partner

Have you previously suffered from this complaint?: Yes

If Yes, enter previous therapist(s) seen for complaint, describe treatment:Khay, talk therapy
Medical history

What medications are you currently using?:-

Previous diagnoses/mental health treatment:**No answer given**

Previously treated by:**No answer given**

Previous medications:**No answer given**

Dates treated:**No answer given**

Previous medical conditions:**No answer given**

Previous surgeries:**No answer given**

Family History

Were you adopted? If yes, at what age?:No

How is your relationship with your mother?:Hot and cold with my late mother, can't remember much of our
relationship. I was always taking care of her when she started getting
chronically sick.

How is your relationship with your father?:Also hot and cold and harder to approach. Tried to amend the
relationship for the past 2 years but I'm still struggling to find the
connection with him.

Siblings and their ages:A brother, 32

Are your parents married?:Yes

 Did your parents divorce? If yes, how old were you?:No

Did your parents remarry? If yes, how old were you?:No

Who raised you? Where did you grown up?:**No answer given**

Family member medical conditions:**No answer given**

Family member mental conditions:**No answer given**

Treated with medication?:**No answer given**

Medications:**No answer given**

Present Situation

Work: Unemployed

Any difficulties in your current role? if yes, please specify: For context, I'm doing livestreaming, freelancing and

taking random projects and jobs from clients. Most of my work requires me to work with brands, people and
social media. Recently my outreach and engagement has been really low since my self esteem issues
reappeared making it harder for me to start or try something which makes it harder for me to accept a lot of
work.

Are you married? If yes, specify date of marriage:No

Are you divorced? If yes, specify date of divorce:No

Prior marriages? If yes, how many?:No

What is your sexual orientation?: Straight

Are you sexually active?: Yes

How is your relationship with your partner?:Codependency, we acknowledge this but we're both having a hard time
trying to fix underlying issues

Do you have child(ren)? If yes, how is your relationship with your child(ren)?:No

Are you a member of a religion/spiritual group?:Yes but non practicing

Have you ever been arrested? If yes, when and why?:No

Have you ever tried the following?

(check all that apply)

Alcohol

Tobacco

Marijuanna

Hallucinogens (LSD)

Heroin

Methamphetamines

Cocaine

Stimulants (Pills)
 Ecstasy

Methadone

Tranquilizers

Pain Killers

Other substances (please list down in the space): **No answer given**

If yes to any, list frequency/dates of use:**No answer given**

Have you ever been treated for drug/alcohol abuse? If yes, when?:No

Do you smoke cigarettes? If yes, how many per day?:No

Do you drink caffeinated beverages? If yes, how many per day?:No

Have you ever abused prescription drugs? If yes, which ones?:Cough syrup. Have stopped using for awhile, had
troubles after mum's passing

Additional

Resources and strengths

What goals do you have in life?: Want to be able to help people and create a brand or business I can be proud

of

What do you like to do for fun?: Livestreaming, going out for walks, hiking, travelling

Who do you go to when you have a problem?: Partner if it gets too much.
 Anything else you want the therapist to know?:No

Nadrah Saufi: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 29/06/2024 07:38 PM MYT
 2. Current mood, anxiety and other feelings

Client Full Name: Nadrah Saufi

Current mood

Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?:

More than half the days

Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?: Several days

Over the last 2 weeks, how often have you been bothered by trouble falling or staying asleep, or sleeping too
much?:

More than half the days

Over the last 2 weeks, how often have you been bothered by feeling tired or having little energy?: Several days

Over the last 2 weeks, how often have you been bothered by poor appetite or overeating?: Several days

Over the last 2 weeks, how often have you been bothered by feeling bad about yourself or that you are a failure or
have let yourself or your family down?:

More than half the days

Over the last 2 weeks, how often have you been bothered by trouble concentrating on things, such as reading the
newspaper or watching television?:

More than half the days

Over the last 2 weeks, how often have you been bothered by moving or speaking so slowly that other people could
have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than
usual?:

Several days

Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of
hurting yourself?:

Not at all

If you checked any problems, how difficult have they made it for you to do your work, take care of things at home,
or get along with other people?:

Very difficult

Current distress
 How much psychological pain are you feeling right now? Psychological pain refers to hurt, anguish, misery in your
mind, and not stress or physical pain:

How much stress are you feeling right now? Stress refers to your general feeling of being pressured or
overwhelmed:

How much agitation do you feel right now? Agitation refers to emotional urgency, feeling that you need to take
action. It does not refer to irritation or annoyance.:

How much hopelessness do you feel right now? Hopelessness refers to your expectation that things will not get
better no matter what you do.:

How much self hate do you feel right now? Self hate refers to your general feeling of disliking yourself; having no
self-esteem; having no self respect.:

Current anxiety

Over the last two weeks, how often have you been bothered by feeling nervous, anxious or on edge?: More than

half the days

Over the last two weeks, how often have you been bothered by not being able to stop or control worrying ?: More

than half the days

Over the last two weeks, how often have you been bothered by worrying too much about different things?: More

than half the days

Over the last two weeks, how often have you been bothered by trouble relaxing?: More than half the days

Over the last two weeks, how often have you been bothered by being so restless that it is hard to sit still?: Several

days

Over the last two weeks, how often have you been bothered by becoming easily annoyed or irritable ?: Several

days

Over the last two weeks, how often have you been bothered by feeling afraid, as if something awful might happen
?:

More than half the days

 If you checked any problems, how difficult have they made it for you to do your work, take care of things at home,
or get along with other people?:

Very difficult

Current bodily pains

During the past 4 weeks, how much have you been bothered by stomach pain?: Not bothered at all

During the past 4 weeks, how much have you been bothered by back pain?: Bothered a little

During the past 4 weeks, how much have you been bothered by pain in your arms, legs, or joints (knees, hips, etc.)
?:

Not bothered at all

During the past 4 weeks, how much have you been bothered by menstrual cramps or other problems with your
periods? (WOMEN ONLY):

Bothered a little

During the past 4 weeks, how much have you been bothered by headaches?: Not bothered at all

During the past 4 weeks, how much have you been bothered by chest pain?: Bothered a little

During the past 4 weeks, how much have you been bothered by dizziness?: Not bothered at all

During the past 4 weeks, how much have you been bothered by fainting spells?: Not bothered at all

During the past 4 weeks, how much have you been bothered by feeling your heart pound or race?: Bothered a

little

During the past 4 weeks, how much have you been bothered by shortness of breath?: Not bothered at all

During the past 4 weeks, how much have you been bothered by pain or problems during sexual intercourse ?:

Bothered a little

During the past 4 weeks, how much have you been bothered by constipation, loose bowels, or diarrhea?:

Bothered a little

During the past 4 weeks, how much have you been bothered by nausea, gas, or indigestion ?: Bothered a little
 During the past 4 weeks, how much have you been bothered by feeling tired or having low energy?: Bothered a

little

During the past 4 weeks, how much have you been bothered by trouble sleeping?: Bothered a little

Nadrah Saufi: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 29/06/2024 07:38 PM MYT
 3. Informed Consent for Psychological Services

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement.
Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us
can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.
Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of
this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on
your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering
unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger,
depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I
can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify
what it is that you want for yourself.

Who can receive services?

You can receive services from Relate Mental Health Malaysia if you are currently residing in Malaysia.
Due to ethical and safety reasons, we can only offer services to you when you are living in Malaysia. If you move
abroad, we will work with you to find other mental health services at your new location.

Location of sessions

Relate Mental Health Malaysia offers in person at our office in Bangsar or online sessions.

For telehealth sessions:

You will need a secure and safe location to have the session and access to high-speed internet which will allow you to
carry out the video conference call with as little disruption as possible.

Length of sessions

i. Intake session:

The first session will last approximately 2 hours. You will be asked to complete two online questionnaires, and be given
a semi-structured diagnostic interview based on the DSM-5-TR. These instruments are the gold standard diagnostic
interviews in the field.
 ii. Psychotherapy sessions

A regular psychotherapy sessions will last 50 minutes on a weekly, bi-weekly, or monthly basis, according to your
needs. Research shows that most people benefit from weekly sessions for at least 12 sessions. Psychotherapy is often
most effective if sessions are held on a weekly basis as this will allow you to make the most therapeutic gains
continuously.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client
requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of
such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is
a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or
actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of
rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best
treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy
and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you
acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any
lengthy discussions in public or outside of the therapy office.

Therapy Progress Questionnaires

As part of making sure you are moving towards your therapy goals and feeling better, you will be asked to complete
online questionnaires before every session.

You can ask me any questions about your progress and about the questions.
Please answer these questions honestly as your answers will help me understand your recovery progress and how I
can care for you more effectively.

i. You will complete the OQ45.2 TA, which is an empirically validated tool to track your therapeutic progress every
week.
 ii. You will also complete the PHQ 9 , PHQ 15, and GAD 7 every 6 sessions.

Your answers will remain confidential and be seen only by me and my clinical supervisor (if applicable).

Relate Mental Health Malaysia may publish aggregated results from these measures from all clients (which may include
your responses), without any personal identifying information, in reports or publications.

Communication

Due to my work schedule, I may not be immediately available by telephone, email, or text message. Every effort will
be made to return your call, email, or text message within 24 hours, with the exception of weekends and holidays.

Crisis

In emergencies, please contact your family physician, call 999, or go to the nearest emergency room.

As we are an outpatient clinic, we do not provide emergency crisis intervention.

At any moment, without financial penalty, you have the right to withdraw your consent by formally notifying Relate
Mental Health Malaysia at [email protected].

Nadrah Saufi: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 29/06/2024 07:38 PM MYT
 4. Consent for Recording

Consent for Video and Audio Recording

Because our organization provides a teaching-training function, permission is frequently requested of its clients to
audiotape and/or videotape the interviews that are conducted by the professionals-in-training. Audio taping and
video recording the sessions are a significant component of counselor training. However, no recording is ever done
unless the client has given permission to do so. Therefore, we use this consent form to obtain your permission to
audiotape and/or video. Feel free to ask your therapist any questions about the purpose of taping and use of the
tapes.

The purpose of taping is for use in training and supervision. This will allow the above referenced therapist to
consult with his or her assigned supervisor(s) in an individual or group supervision format, who may listen to the
tape alone or in the presence of other psychologists who involved in direct supervision.

The contents of these taped sessions are confidential and the information will not be shared outside the context of
individual and group supervision.

The tapes will be stored in a secure location and will not be used for any other purpose without my explicit written
permission.

The tapes will be erased after they have served their purpose.

Nadrah Saufi: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 29/06/2024 07:38 PM MYT
 5. Payment policies

Payment policies
1. I understand that I have to pay 48 hours in advance before my therapy session.

2. I understand that I will be charged the full fee of the therapy session IF

i. I fail to give at least 24 hour notice prior to cancelling my appointment OR

if I fail to show for my appointment.

3. I understand that if I do not pay by 24 hours in advance before my therapy session, it will be automatically
rescheduled so that I do not pay additional fees (point 2).

4. I understand that the therapy session will last 50 minutes. I understand that if I am late to the appointment, I will
still have to end the session at the allotted time.

By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this
therapist.

Nadrah Saufi: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 29/06/2024 07:38 PM MYT