Social Work and Counselling Case Intake Form Are you applying for yourself or on behalf of someone else? SelfOn Behalf Client's Particulars Full Name as per NRIC/FIN/Passport Last 4 characters of your NRIC/FIN/Passport No. e.g.123A Contact No. Email Residential Address Gender MaleFemale Date of Birth Race ---ChineseIndianMalayEurasianOthers Nationality ---SingaporeanSingapore PROthers Marital Status ---SingleMarriedWidowedDivorcedSeparated Spoken Language(s) EnglishMandarinMalayTamilOthers Area(s) of Need Please provide a short write-up of the issues faced (E.g. financial difficulty due to loss of job) Please indicate if you/client were previously known to PCS YesNo Please indicate if you/client is related to or know any PCS staff on a personal basis YesNo Name of PCS Staff Relationship to PCS Staff ---Family MemberRelativeOthers Referred By Name of Referral Person Contact No. Email Are you a staff of PCS? YesNo Relationship to Client Personal Data Protection Act (PDPA) clause: In compliance with the Personal Data Protection Act, Presbyterian Community Services is committed to protecting personal data we have collected from you. By providing your personal details in the process of this application, you are consenting for Presbyterian Community Services to use your personal data or disclose your personal data to third parties where necessary for the following purposes: assessing and evaluating your application for financial assistance, verifying your identity and accuracy of your personal details and other information provided, administration of the financial assistance, contacting you about and involving you in our activities, research and evaluation, and making a referral to another agency. I agree / Client has agreed to be contacted by a social work professional in Presbyterian Community Services.