Intake form EN

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

* Indicates required field

Name *

First

Last

Gender *

Male Female Other

Date of birth *

Place of Birth *

BSN *

Marital status *

Occupation *

Address *

Postal Code *

Town *

Telephone number *

E-mail address *

General Practitioner

Name *

Address *

Telephone number *

E-mail address *

FOCUS PROBLEM:
Can you describe the situation/problem that you would like to bring in therapy?

Comment *

How long have you had this problem? *

Additional Information: *

Which doctor, specialist or counsellor did you consult about this problem? *

What was the diagnosis of the general practioner/specialist? *

What are the recommendation of the general practitioner/specialist? *

Are you currently in medical / psychological / psychiatric treatment? *

Yes No

If you have answered yes to the previous question: by whom? *

Telephone number *

E-mail address *

Diagnosis *

What has been the result until now? *

Are you using any form of medication or drugs , recreational drugs or alcohol in any form? *

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. *

What do you want to achieve with this therapy? *

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. *

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. *

Yes

HOW DID YOU FIND MY NAME *

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

Intake Form

Client information

General Practitioner

FOCUS PROBLEM:Can you describe the situation/problem that you would like to bring in therapy?

FULLY AND TRUTHFULLY FILLED IN ​

FOCUS PROBLEM:
Can you describe the situation/problem that you would like to bring in therapy?

FULLY AND TRUTHFULLY FILLED IN