Name: Date of Birth: Country of Origin: Preferred language: Phone number: Is it safe to contact you at this number? YesNo If no, please state alternative contact methods: Your email: Emergency contact: Relationship with emergency contact: Emergency contact number: Type of support preferred: On-line (live chat)On-line (voice/video call)In-person
Marital status: SingleMarriedWidowed
Main concern (Please circle/tick as many as apply) Intense sadnessAnxietyProblems eatingInability to sleepIrritabilityConcentration difficultiesNightmaresLack of motivationGrief/LossFrequent cryingLoss of hopePanic attacksChange of countryAngerExplosive outburstsExcessive behaviours
Do you have a history of suicidal thoughts? YesNo
Please describe briefly your current main concern:
Have you ever engaged in counselling / therapy? YesNo If so, can you briefly describe the experience?
Do you currently have a psychiatrist, or had any psychiatrist recently? YesNo If so, are you currently on any medication?
Do you suffer from any medical conditions? YesNo If so, what:
Are you on any medication? YesNo If so, what:
Do you require any special adjustments (i.e. a ramp for entrance, quiet environment, extra time in session, etc.)? YesNo If so, what:
I am hereby consenting to the processing and collecting of my personal and sensitive data by Tama, such data being provided herein or delivered at a later stage directly or indirectly through Tama’s email, and I understand that such information is processed and collected in order for Tama to be able to complete my mental health needs profile and assessment, and confirm that I can be assisted by appropriate professionals, in which case my details will be kept on an internal register of service users
In case appropriate professionals within Tama would be found to assist me, I am hereby further giving my consent so that a restricted amount of my personal and sensitive data, that would be required so that I might be able to be given a service appropriate to my mental health needs, and cultural, linguistic and disability-specific requirements, would be shared with those Tama officials who would be responsible for arranging and delivering mental health services to me In case appropriate professionals outside of Tama would be found to assist me, I understand that I would be given specific details of these professionals, and asked to give further consent separately, in order to use their services, once Tama would have referred me to them I undertake to notify and keep Tama updated of any changes to the personal data that I am providing through this form I consent to Tama using my personal data to send me details of initiatives organised by Tama or by any of its partners
Privacy Policy Tama (registered with the Commissioner for Voluntary Organisations (Malta) – VO/1914) shall retain my personal data for a maximum of three (3) years. I shall be entitled to request access to my personal data, a copy of which will be provided by Tama together with this policy notice, and to correct or amend such data. Moreover, I may request Tama to restrict the processing of such data until data is corrected or amended. I have a right to request Tama to delete and remove any such data, either when there is no good reason for Tama to continue processing it, or when such a right ensues at law. My data will be processed in accordance with the European Union (EU) General Data Protection Regulation (GDPR) (Regulation (EU) 2016/679) and the Maltese Data Protection Act (Cap. 586). My personal data shall not be passed on by Tama to any third parties, whether or not these parties are connected with Tama’s aims, unless I have given explicit consent for Tama to do so at any point, and I also have the option to withdraw or change the terms of this consent at any point. I should contact Tama in writing at in order to exercise such rights, and for obtaining any further information. I shall also have a right to lodge a complaint with the Office of the Information and Data Protection Commissioner (IDPC), Malta's supervisory authority responsible for data protection. I have read and understood the above Privacy Policy, and I accept it
