適用於香港中文大學全日制學生 Eligible to full-time students only * = 必填項目 Required field
本地學生如有豐富的非本地文化背景（如曾就讀國際學校，或在香港出生的少數族裔人士）亦可申請 Only applicable to local students with extensive exposure to cultural experiences outside Hong Kong, e.g. those with international school background, or ethnic minorities born in Hong Kong.
我同意接受香港中文大學心理健康及輔導中心(WACC)的轉介，接受聖約翰輔導服務(SJCCS)的多元文化心理輔導服務計劃。 中文大學心理健康及輔導中心會將我的資料發送予聖約翰輔導服務，用作多元文化心理輔導服務計劃的轉介。發送的資料包括姓名、聯繫方法、所屬學院、學系、學年、精神健康檢測 (GHQ) 問卷結果、和初步評估中討論的資料（如適用）。 我明白及了解聖約翰輔導服務將回覆心理健康及輔導中心和轉介人（如適用）關於我是否參加了初步評估，以及是否接受聖約翰輔導服務的進一步諮詢。 通過簽署本協議，我理解並確認其條款。 I agree to receive multicultural psychological counselling service at St John’s Cathedral Counselling Service as referred by Wellness and Counselling Center (WACC), the Chinese University of Hong Kong. For the purpose of referral for multicultural psychological counselling, WACC will release my information to St John’s Cathedral Counselling Service. Information released include my name, contact information, college, study program, year of study, other information on this form, general health questionnaire (GHQ) results and information discussed in Triage session in WACC (if applicable). I understand that St John’s Cathedral Counselling Service will reply to WACC and the referrer (if applicable) whether I have attended the initial assessment session(s) and whether I accept further counselling in St John’s Cathedral Counselling Service. By signing this agreement, I understand and acknowledged its terms.