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PSYCHOEDUCATIONAL REFERRALS
Mental Health Related Support
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Enquire for Mental Health Related Support
Please complete all required fields and sections.
Select for which purpose you want to enquire:
Registering or Enquiring about Psychoeducational Assessments (6 to 21 yrs old) / Literacy and Language Interventions (7-12 yrs old)
Enquire for Mental Health Related Support
General Enquiry Form
Errors:
Enquiry Details
Family Information
Medical and Service Information
Consent
Please fill in the details of the child/youth requiring our services (yourself or someone known to you)
Name as per NRIC
Preferred Name
Last 4 characters of NRIC
Biological Sex
--Select Gender--
Male
Female
Date of birth
Citizenship
-- Citizenship --
American
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Singapore PR
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Race
-- Select --
African
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Thai
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Block/Unit Number
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Building Name
Country
-- Select Country --
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Malaysia
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Mali
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Mexico
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Vietnam
Western Sahara
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Zimbabwe
Postal Code
Email Address
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Alternative Contact number
School/Employed
--Select--
Full time studies (kindergarten)
Full time studies (primary)
Full time studies (secondary)
Full time studies (polytechnic)
Full Time Studies (ITE)
Full Time Studies (JC)
Full time studies (University or Others)
Part Time Studies
Full Time Employment
Part Time Employment
Unemployed (above 16 years old, Neither Schooling or Working)
Serving NS
Unengaged (schooling age but not schooling)
Date of Withdrawal
Child's School
-- Select --
Admiralty Primary School
Admiralty Secondary School
Ahmad Ibrahim Primary School
Ahmad Ibrahim Secondary School
Ai Tong School
Alexandra Primary School
Anchor Green Primary School
Anderson Primary School
Anderson Secondary School
Anderson Serangoon Junior College
Ang Mo Kio Primary School
Ang Mo Kio Secondary School
Anglican High School
Anglo-Chinese Junior College
Anglo-Chinese School (Barker Road)
Anglo-Chinese School (Independent)
Anglo-Chinese School (Junior)
Anglo-Chinese School (Primary)
APSN Chaoyang School
APSN Delta Senior School
APSN Katong School
APSN Tanglin School
Assumption English School
Assumption Pathway School
AWWA School @ Bedok
AWWA School @ Napiri
Balestier Hill Primary School
Balestier Hill Secondary School
Bartley Secondary School
Beacon Primary School
Beatty Secondary School
Bedok Green Primary School
Bedok Green Secondary School
Bedok North Secondary School
Bedok South Secondary School
Bedok Town Secondary School
Bedok View Secondary School
Bedok West Primary School
Bendemeer Primary School
Bendemeer Secondary School
Bishan Park Secondary School
Blangah Rise Primary School
Boon Lay Garden Primary School
Boon Lay Secondary School
Bowen Secondary School
Broadrick Secondary School
Bukit Batok Secondary School
Bukit Merah Secondary School
Bukit Panjang Govt. High School
Bukit Panjang Primary School
Bukit Timah Primary School
Bukit View Primary School
Bukit View Secondary School
Canberra Primary School
Canberra Secondary School
Canossa Convent Primary School
Canossian School
Cantonment Primary School
Casuarina Primary School
Catholic High School
Catholic Junior College
Cedar Girls' Secondary School
Cedar Primary School
Cerebral Palsy Alliance Singapore School (East)
Cerebral Palsy Alliance Singapore School (West)
Changkat Changi Secondary School
Changkat Primary School
Chatsworth International School
Chestnut Drive Secondary School
Cheston Montessori Preschools
CHIJ (Katong) Primary
CHIJ (Kellock)
CHIJ Katong Convent
CHIJ Our Lady Of Good Counsel
CHIJ Our Lady Of The Nativity
CHIJ Our Lady Queen Of Peace
CHIJ Primary (Toa Payoh)
CHIJ Secondary (Toa Payoh)
CHIJ St. Joseph's Convent
CHIJ St. Nicholas Girls' School
CHIJ St. Theresa's Convent
Chong Boon Secondary School
Chong Fu Primary School
Chongzheng Primary School
Christ Church Secondary School
Chua Chu Kang Primary School
Chua Chu Kang Secondary School
Chung Cheng High School (Main)
Chung Cheng High School (Yishun)
Clementi Primary School
Clementi Town Secondary School
Clementi Woods Secondary School
Commonwealth Secondary School
Compassvale Primary School
Compassvale Secondary School
Concord Primary School
Coral Primary School
Coral Secondary School
Corporation Primary School
Crescent Girls School
Crest Secondary School
Da Qiao Primary School
Damai Primary School
Damai Secondary School
Darul Makmur Mosque
Dazhong Primary School
De La Salle School
Deyi Secondary School
Dunearn Secondary School
Dunman High School
Dunman Secondary School
East Coast Primary School
East Spring Secondary School
East View Primary School
East View Secondary School
Eden School
Edgefield Primary School
Edgefield Secondary School
Elias Park Primary School
Endeavour Primary School
Eunoia Junior College
Evergreen Primary School
Evergreen Secondary School
Fairfield Methodist School (Primary)
Fairfield Methodist School (Secondary)
Farrer Park Primary School
Fengshan Primary School
Fernvale Primary School
First Toa Payoh Primary School
First Toa Payoh Secondary School
Foodpanda
Fuchun Primary School
Fuchun Secondary School
Fuhua Primary School
Fuhua Secondary School
Gan Eng Seng Primary School
Gan Eng Seng School
Geylang Methodist School (Primary)
Geylang Methodist School (Secondary)
Gongshang Primary School
Grace Orchard School
Greendale Primary School
Greendale Secondary School
Greenridge Primary School
Greenridge Secondary School
Greenview Secondary School
Greenwood Primary School
Griffiths Primary School
Guangyang Secondary School
Hai Sing Catholic School
Haig Girls' School
Henderson Secondary School
Henry Park Primary School
Hillgrove Secondary School
Holy Innocents' High School
Holy Innocents' Primary School
Hong Kah Primary School
Hong Kah Secondary School
Hong Wen School
Horizon Primary School
Hougang Primary School
Hougang Secondary School
Hua Min Primary School
Hua Yi Secondary School
Hwa Chong Institution
Innova Primary School
ITE College Central
ITE College East
ITE College West
JBM
Jiemin Primary School
Jing Shan Primary School
Junyuan Primary School
Junyuan Secondary School
Jurong Pioneer Junior College
Jurong Primary School
Jurong Secondary School
Jurong West Primary School
Jurong West Secondary School
Jurongville Secondary School
Juying Secondary School
Kaplan Inc
Keming Primary School
Kent Ridge Secondary School
Kheng Cheng School
Kong Hwa School
Kranji Primary School
Kranji Secondary School
Kuo Chuan Presbyterian Primary School
Kuo Chuan Presbyterian Secondary School
LA SALLE
Lakeside Primary School
Lianhua Primary School
Lighthouse School
Loyang Primary School
Loyang Secondary School
Macpherson Primary School
Macpherson Secondary School
Madrasah Al-Arabiah Al-Islamiah
Madrasah Al-Irsyad Al-Islamiah
Madrasah Aljunied Al-Islamiah
Madrasah Al-Maarif Al-Islamiah
Madrasah Alsagoff Al-Islamiah
Madrasah Wak Tanjong Al-Islamiah
Maha Bodhi School
Maitri School
Manjusri Secondary School
Maris Stella High School
Marsiling Primary School
Marsiling Secondary School
Marymount Convent School
Mayflower Primary School
Mayflower Secondary School
Mee Toh School
Meridian Primary School
Methodist Girls' School (Primary)
Methodist Girls' School (Secondary)
Metta School
Millennia Institute
MINDS Fernvale Gardens School
MINDS Lee Kong Chian Gardens School
MINDS Towner Gardens School
MINDS Woodlands Gardens School
MOE Kindergarten
Montfort Junior School
Montfort Secondary School
My First Skool
My First Skool
My Kidz Cottage
My World
Nan Chiau High School
Nan Chiau Primary School
Nan Hua High School
Nan Hua Primary School
Nanyang Girls' High School
Nanyang Junior College
Nanyang Polytechnic
Nanyang Primary School
Nanyang Technological University (NTU)
National Junior College
National University of Singapore (NUS)
Naval Base Primary School
Naval Base Secondary School
New Town Primary School
New Town Secondary School
Ngee Ann Polytechnic
Ngee Ann Primary School
Ngee Ann Secondary School
North Spring Primary School
North View Primary School
North View Secondary School
North Vista Primary School
North Vista Secondary School
Northbrooks Secondary School
Northland Primary School
Northland Secondary School
Northlight School
Northlight Secondary School
Northoaks Primary School
Northshore Primary School
Northview Primary School
NUS High School Of Mathematics And Science
Opera Estate Primary School
Orchid Park Secondary School
Others
Out of School
Outram Secondary School
Palm View Primary School
Park View Primary School
Part Time Employment
Pasir Ris Crest Secondary School
Pasir Ris Primary School
Pasir Ris Secondary School
Pathlight School (Ang Mo Kio Ave 10)
Pathlight School (Ang Mo Kio Street 44)
Pathlight School (Tampines)
Paya Lebar Methodist Girls' School (Primary)
Paya Lebar Methodist Girls' School (Secondary)
PCF Sparkletots
Pei Chun Public School
Pei Hwa Presbyterian Primary School
Pei Hwa Secondary School
Pei Tong Primary School
Peicai Secondary School
Peirce Secondary School
Peiying Primary School
Pioneer Primary School
Pioneer Secondary School
Poi Ching School
Presbyterian High School
Princess Elizabeth Primary School
PSB Academy
Punggol Primary School
Punggol Secondary School
Punggol View Primary School
Qiaonan Primary School
Qifa Primary School
Qihua Primary School
Queenstown Primary School
Queenstown Secondary School
Queensway Secondary School
Radin Mas Primary School
Raffles Girls' Primary School
Raffles Girls' School (Secondary)
Raffles Institution
Rainbow Centre Admiral Hill School
Rainbow Centre Margaret Drive School
Rainbow Centre Yishun Park School
Red Swastika School
Regent Secondary School
Republic Polytechnic
River Valley High School
River Valley Primary School
Riverside Secondary School
Rivervale Primary School
Rosyth School
Rulang Primary School
School of Science and Technology Singapore
School Of The Arts, Singapore
Sembawang Primary School
Sembawang Secondary School
Seng Kang Primary School
Seng Kang Secondary School
Serangoon Garden Secondary School
Serangoon Secondary School
Sheffield Kids World
SHINE Clementi Centre
SHINE Hougang Centre
SHINE Tiong Bahru Centre
SHINE Yishun Centre
Shopee (Warehouse)
Shuqun Primary School
Shuqun Secondary School
Si Ling Primary School
Si Ling Secondary School
Siglap Secondary School
Singapore Chinese Girls' Primary School
Singapore Chinese Girls' School
Singapore Institute of Technology (SIT)
Singapore Management University (SMU)
Singapore Polytechnic
Singapore Sports School
Singapore University of Social Sciences (SUSS)
Singapore University of Technology and Design (SUTD)
South View Primary School
Sparkle Tots
Springfield Secondary School
St Andrew's Junior College
St Andrew's Junior School
St. Andrew’s Autism School
St. Andrew’s Mission School
St. Andrew's Secondary School
St. Anthony's Canossian Primary School
St. Anthony's Canossian Secondary School
St. Anthony's Primary School
St. Gabriel's Primary School
St. Gabriel's Secondary School
St. Hilda's Primary School
St. Hilda's Secondary School
St. Joseph's Institution
St. Joseph's Institution Junior
St. Margaret's Primary School
St. Margaret's School (Secondary)
St. Patrick's School
St. Stephen's School
Sweetlands Childcare
Swiss Cottage Secondary School
Tampines Meridian Junior College
Tampines North Primary School
Tampines Primary School
Tampines Secondary School
Tanglin Secondary School
Tanjong Katong Girls' School
Tanjong Katong Primary School
Tanjong Katong Secondary School
Tao Nan School
Teck Ghee Primary School
Teck Whye Primary School
Telok Kurau Primary School
Temasek Junior College
Temasek Polytechnic
Temasek Primary School
Temasek Secondary School
Touch Preschool
Townsville Primary School
Unemployed
Unity Primary School
Unity Secondary School
Unknown
Victoria Junior College
Victoria School
Waterway Primary School
Wellington Primary School
West Grove Primary School
West Spring Secondary School
West View Primary School
Westwood Primary School
Westwood Secondary School
White Sands Primary School
Whitley Secondary School
Wildflower Studio @ Enabling Village
Wolsey Hall Oxford
Woodgrove Primary School
Woodgrove Secondary School
Woodlands Primary School
Woodlands Ring Primary School
Woodlands Ring Secondary School
Woodlands Secondary School
Xinghua Primary School
Xingnan Primary School
Xinmin Primary School
Xinmin Secondary School
Xishan Primary School
Yangzheng Primary School
Yew Tee Primary School
Yio Chu Kang Primary School
Yio Chu Kang Secondary School
Yishun Innova Junior College
Yishun Primary School
Yishun Secondary School
Yishun Town Secondary School
Yu Neng Primary School
Yuan Ching Secondary School
Yuhua Primary School
Yuhua Secondary School
Yumin Primary School
Yusof Ishak Secondary School
Yuying Secondary School
Zhangde Primary School
Zhenghua Primary School
Zhenghua Secondary School
Zhonghua Primary School
Zhonghua Secondary School
School (Others)
Religion
-- Select Religion --
Buddhism
Catholicism
Christianity
Hinduism
Islam
No Religion
Others
Sikhism
Taoism
Your Prefered Language
English
Mandarin
Malay
Tamil
Your Preferred Mode of Contact
--Select--
Phone Call
Telegram
Email
Whatsapp
Text Message
Name of Emergency Contact (must be above 21 years old)
Emergency contact
Relationship to Emergency contact
--Select--
Parent/Caregiver
Sibling
Partner
Relative
Friend
Helping Professional
Teacher/School Counsellor
Family Information
Please continue to fill the following as best as able.
Parent/Guardian's Name
Parent/Guardian's Contact Number
Parent/Guardian's Preferred Language
English
Mandarin
Malay
Tamil
Parent/Guardian's E-mail
Parent/Guardian's Employment Status
--Select--
Employed - Full Time
Employed – Part Time
Self-Employed
Retired/Homemaker
Unemployed
Choose Not To Disclose
Unsure
Second Parent/Guardian's Name
Second Parent/Guardian's Contact Number
Second Parent/Guardian's Preferred Language
English
Mandarin
Malay
Tamil
Second Parent/Guardian's Email
Primary Caregiver (Person(s) who spend time looking after you (youth) or child)
--Select--
One Parent (Mother)
Both Parents
Relatives
Others
One Parent (Father)
Family Combined Gross Income (please estimate if you are unsure)
No. of Household Members (Including child/youth)
Family Type
--Select--
Nuclear (i.e., 2 parents)
Single Parent
Reconstituted (i.e, Remarried)
Multi-generational
Others
Living Arrangements
--Select--
Immediate Family
Relatives
Others
Housing Type
--Select--
1-Room
2-Room
3-Room
4-Room
5-Room
3Gen
Executive
Private(Condo or Landed)
Institutional Care
Other(To Indicate in the next question)
Housing Type (Others)
Housing Ownership
--Select--
Purchased
Private Rental
Public Rental
Medical And Service Information
Please continue to fill the following as best as able.
My (youth)/Child's Formal Mental Health Diagnosis (If applicable)
I (youth) am /child is currently receiving mental health related services
--Select--
Yes
No
Not Applicable
Indicate ongoing support / treatment and if services will continue after the referral. If yes, please elaborate
If I (myself) or the youth is not staying in the service region (West; Boon Lay, Bukit Batok, Bukit Panjang, CCK, Clementi, Jurong East, Queenstown, Taman Jurong) of ResiL!ence @ SHINE, I am agreeable to be referred to an agency nearer my residence with similar services
--Select--
Yes
No, I prefer/youth prefers services from ResiL!ence @ SHINE
Services I am seeking for myself (enquirer: for youth) / my child (enquirer: parents/caregivers) / caring young person (enquirer: helping professional) - may choose more than 1
1) Mental health screening is a once-off, 45 - 90mins session, helping you understand your mental health state and actions to take to care of your wellbeing.
2) Mental health assessment is a once-off 90 - 120mins session, helping you to understand your psychological functioning and need for appropriate care services
3) Social emotional support is a 6 - 9 month support via text-based checks-ins, meet-ups, peer supporting, and/or group based activities to aid you in improving your mental state
4) Counselling services is a 12 - 18 months support via talk therapy in 121 group and/or family settings
5) Myloh (My Life of Hope), an e-buddy app for youths aged 12 - 25 years old. It was developed by a start-up, myloh, in recognition of the rising mental health struggles among youths. Provide holistic support to individuals, with features to promote the mental well-being
6) Newsletter, our quarterly newsletter containing articles on youth mental health and resources, available on www.bit.ly/LghtUp
7) Support to prevent caregiver burnout which includes resource sharing, light touch support, referral to support groups and relevant services (for caregivers/parents)
8) Other mental health related programme(s)
Mental health screening to understand mental state
Mental health assessment to understand psychological functioning
Social emotional support to improve mental state
Counselling service to improve well being
Myloh, mental wellness e-buddy app
Newsletter to improve literacy on youth mental health
Caregiver support to prevent caregiver burnout
Other mental health related programme(s)
Reasons I am reaching out (Please share with us why you believe you or your child or the youth need support and/or the indicated services. eg: having troubles coping with exam stress, no longer interested in activities, as well as any significant trigger events, onset and duration of changes observed)
I found out about ResiL!ence via
--Select--
Family Members
Friends
Google Search
SHINE Website
RL! Instagram (@ministryofmental)
RL! Newsletter (L!ght Up)
From roadshows/Workshops/Talks in the Community
Others (to indicate in the next question)
I found out about ResiL!ence via (Others)
Are you assisting to refer a child/youth
--Select--
No (I am a youth myself)
Yes (I am a helping professional or parent/caregiver)
Please let us know how to contact you and continue to fill the following where relevant/as best as able.
Relationship to Contact
--Select--
Helping Professional (i.e., School Counsellor, Social Worker)
Parent/Caregiver (ie., Father, Mother, Grandparent, Relatives, Guardian, Sibling)
Name of Person who Enquired
Organization (programme)/School You Are Referring From (if applicable)
Contact Number of Enquirer
Email of Enquirer
Has the youth / child consented to this referral?
--Select--
Yes
No
Is the youth/child aware of the information (e.g., mental health concerns, safety concerns) you will be disclosing to us?
--Select--
Yes
No
Youth/child's Responsiveness to Services
--Select--
Low
Moderate
High
Not Applicable
Parent/Caregiver's Responsiveness to Services
--Select--
Low
Moderate
High
Not Applicable
Is there active non-suicidal self-injury (NSSI) behaviours?
--Select--
Yes
No
Unsure
Indicate youth's/child's methods, frequency, alternative recommended to NSSI behaviours (if applicable)
Does the youth/child has active suicide ideation?
--Select--
Yes
No
Unsure
Indicate risk level, past attempts, and deterrents (if applicable)
Is the parent/caregiver aware of youth/child's active suicide ideation?
--Select--
Yes
No
Unsure
Does the youth / child has a safety plan?
--Select--
Yes
No
Not Applicable
Has the youth's parent/caregiver consented to the referral?
--Select--
Yes
No
If you require updates, please elaborate updates required
Identified youth's asset(s)/interest(s)
Hopes of youth in general or for this referral
Hope of caregiver in general or for this referral
Recommended Referral Arrangements
--Select--
Contact Parent aregiver Directly
Contact Youth Directly
Joint Session
Referral Link up
Consent
I acknowledge that I have read and understood SHINE’s Data Protection Notice (also available on our website www.shine.org.sg), and consent to the collection, use and disclosure of my personal data by SHINE Children and Youth Services for the purposes set out in the Notice.
I consent to the collection and use of my and/or my family member’s photographs and other audio-visual information.
Submit
Add Preferred Language
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Language Skill
--Select--
Spoken
Written
Language
--Select--
Chinese / Mandarin
English
Malay
Tamil
Hokkien
Teochew
Cantonese
Others
Other Language
Proficiency
--Select--
Good
Average
Poor