Intake Form
Would you kindly complete this form and submit it at least one day before your appointment.
Don't hesitate to contact me if you have any questions
Client information
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Indicates required field
Name
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First
Last
Gender
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Male
Female
Other
Date of birth
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Place of Birth
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BSN
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Marital status
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Unmarried
Cohabitant
Married
Divorced
Altro
Occupation
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Address
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Postal Code
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Town
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Telephone number
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E-mail address
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General Practitioner
Name
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Address
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Telephone number
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E-mail address
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FOCUS PROBLEM:
Can you describe the situation/problem that you would like to bring in therapy?
Comment
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How long have you had this problem?
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Additional Information:
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Which doctor, specialist or counsellor did you consult about this problem?
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What was the diagnosis of the general practioner/specialist?
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What are the recommendation of the general practitioner/specialist?
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Are you currently in medical / psychological / psychiatric treatment?
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Yes
No
If you have answered yes to the previous question: by whom?
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Telephone number
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E-mail address
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Diagnosis
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What has been the result until now?
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Are you using any form of medication or drugs , recreational drugs or alcohol in any form?
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Yes
No
Yes, but not regularly
Occasionally
If you didn't answer 'no', please specify what do you use and with what frequency and dosage.
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What do you want to achieve with this therapy?
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Do you agree that your email address will be passed on to the Association of Integral Therapists (V.I.T.), the professional association of the therapist so that you can be approached after completing therapy for a client satisfaction survey? The research is completely anonymous and your email address is only used for the invitation to the online questionnaire to fill in.
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Yes
No
In my practice I use the privacy regulations as included in the General Data Protection Regulation (AVG). For this reason, I request your permission to record your data in your client file.
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Yes
HOW DID YOU FIND MY NAME
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Another clients told me about you
My doctor gave me your name
I found you with google
I found you on linkedin
I found your facebook page
I found your business card
Other
FULLY AND TRUTHFULLY FILLED IN
Name
*
First
Last
Date
*
I agree to the terms and conditions
*
Yes
Terms and Conditions
I agree to receiving marketing and promotional materials
Submit