Preliminary application form for the first appointment

To save time,we would greatly appreciate your co-operation.
Rest assured that we will not sell, give, or trade your personal information.
Please fill out all the items flagged with an asterisk(*).
You are...

If you are foreign residents, we will ask to bring your foreign registration card or residence card.
Please note that we can not see you if you are illegal aliens.
Your name:
Given name 
First name 

Please spell your name in the given-name-first order.
your gender

please check the box on the form:Female or Male
Your age
Your home country

Kindly take a few minutes and fill out your home country.
Prefectural and city governments where you live now.
Your mobile phone numbers that can be contacted.
 -  - 
Please fill out this application by English one byte characters.
Your e-mail address

Please type your E-mail address in again to confirm it.
occupational spectra.

Please fill out if possible.
Do you have health insurance?(Include Japanese Health Insurances)

If you don't have any health insurance, We'll have to ask you to pay medical fee at your own expense.
If you checked ”Yes” in the above-question about the health insurance and you hope to use it ,would you please let us know about the kind of insurance?

If you checked ”Yes” in the above-question and you hope to use it ,it is compulsory input.
If possible , please enter your kind of health insurance.:e.g(Japanese health insurance,national health insurance or private insurance.)
If not ,there is no need to input.
Please note that even if English-speaker’s patients hope to use Japanese health insurance , Doctor's translation fee will be added.
For English-speaker's customers who think it is unnecessary to see the doctor in English: If it comes across as being rude of us, we deeply apologize for asking for the translation fee. Please keep in mind that we never have any ideas of discriminating you at all. If you think it is unnecessary to see the doctor in English, we'll never ask you for the fee. If you let us know in advance by this mail form, we appreciate it.
Reading the above explanation about the doctor’s translation fee , could you consent ?

(e.g.for first 30 min we charge you 3,000JPN yen. After 30min, we charge you 1500JPN yen+ for every ten minutes . this is the case when you use Japanese health insurance.)
If you disagree, please choose ”No” , or cancel this form.
Do you hope to see the doctor in English?

If you choose ”Yes”, we'll ask you for doctor’s translation fee.
*Attention: We are sorry. We can not accept ADD or ADHD patients to administer medical treatment and medications .
And also , if you have any kind of suicidal idea or symptoms of eating disorders,
we can not accept you to administer medical treatment and medications .
Do you agree with the above content?

When you can’t agree, please cancel to mention this application form.
Symptoms that you are suffering from....

Please check all that apply.
If you chose ”Others”, please write your symptoms at the comment field below in the clearest terms possible.
Do you hope to receive counseling treatment?

Please understand that according to Japanese Health Insurance Act, any kind of Japanese health insurances do not cover the counseling fee .(Till50min:¥8500yen)
How did you find this office?

You can choose multiple selection
For your action:
Our consultation hours: Thursday and Friday:11.00a.m-14.00p.m.16.00p.m-19.00p.m
Please enter the first visit date and time of the first request and the second request .
Comment field

Please leave your message here. (e.g.:Your other symptoms or troubles that you are suffering from.)