Registration

Name:

Address:

ZIP code and address:

Phone:

E-mail:

Previous forms of assistance:

Age of current family members:

Age parents / brothers / sisters:

Do you have experience with other practitioners:

When was that and with whom:

Most important events that happened to you in your family:

Did you have negative sexual experiences as a child or adult?:

Are there psychiatric diseases in the family?:

Have you ever experienced radical / traumatic experiences:

If yes which one:

Which important events are now at the forefront:

Are you married or is there a lasting relationship?:

Have you ever been married before or have you previously had a sustainable realia?:

Are there important events around a relationship?:

Are there specialities with regard to study work and / or career:

Which hobbies were there in the past:

What hobbies are there now:

Are there physical complaints, physical disorders:

Is there alcohol / substance use:

If so; what, when and to what extent:

Use your medication and if so, which medication:

What other information is still important:

What is your request for help?:

What do you want to change:

What are your pitfalls:

What are your qualities:

How would others describe you:

What are your ideas about treatment; for example, duration and kind of help:

Do you have a preference for a man or woman as a therapist?:

Contact