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Intake Form
Please fill in the information below
Part 1: Your Contact Details
*required fields
Name*
Email*
WhatsApp or Telegram Nr.*
Part 2: Your Personal Details
Age*
Preferred Pronouns?
Part 3: Your Health
Health situation
in the past and now
Current medication
From the list below, highlight the areas that concern you:
Addictions
AD(H)D
Alcohol
Aggression
Anorexia
Anxiety
Apathy
Astma
Bulimia, Binge eating
Bipolar disorder
Borderline personality disorder
Boundaries
Burn-out
Career Issues
Childhood (problems from your childhood)
Children (problems with your children)
Chronic fatigue
Co-dependency
Concentration and focus
Confidence
Control issues
Depression
Drugs
Eating disorders
Eating and diet (in general)
Emotional management
Epilepsy
Erectile dysfunction
Exams
Exercise
Fertility
Gambling
Gender identity
Guilt
Hair growth
Hallucinations
Headaches
Interview skills
Insomnia
Imposture syndrome
IVF
Memory
Motivation
Nail-biting
Nervousness
Obsessive compulsive disorder (OCD)
Orgasmic dysfunction
Overweight
Pain (in general)
Pain during sex
Panic attacks
People pleasing
Phobias
Pregnancy
Procrastination
PTSD
Public speaking
Relationships
Relaxation
Schizophrenia
Self-esteem
Sexual orientation
Sexual problems
Shame
Skin problems
Sleep problems (in general)
Smoking
Social anxiety
Somatoform disorder
Sports performance
Speech impediment
Stage fright
Stress
Suicidal
Unhealthy lifestyle
Anything else?
please specify
Part 4: Your Expectations
What would you like to work on in this session?*
What would your life be like without the problem?
Please describe
What are you particularly proud of in your life?
Is there anything else you would like to add?
How did you find me?*
Before submitting this intake form, please acknowledge that you have read and agree to the
waver
and
privacy-policy
.
I confirm that to my knowledge I do not have any of the following disorders: epilepsy, multiple personality disorder, schizophrenia, psychosis and do not have any psychotic symptoms, such as hallucinations.
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