EN - Terms, personal info

Before filling out the form below to request an initial consultation, please read through the following information:

The terms and conditions of my services, inluding:

Please note that,

An initial consultation is charged at the standard price of a regular session
I do not offer sessions in the evenings after 5:30pm or at weekends
I only work with clients over 17 years of age

I confirm that I am over 17 years of age.

I have read the above information, can come to the sessions during the indicated office hours and agree to the indicated fees and conditions.

Service you are interested in

First name

Last name

Salutation

e.g. Dear ,

Please enter your date of birth below. Tip: the year can be changed by clicking on it and using the two arrows that appear in order to adjust the value.

Date of birth

E-mail

Tel. / Mobile

Are the costs to be covered by you privately or by a company?

Privately

From a company

What is the name of the company or organisation that will pay the costs?

Address for invoicing purposes

Address Line 1

Address Line 2

City

Post / ZIP code

Land

Private address

Address Line 1

Address Line 2

City

Post / ZIP code

Land

Please enter the names of all family members who will be attending sessions and their e-mail addresses. You can add further family members by clicking the plus symbol to the right of the row.

Family members' contact information

Name	E-mail address

Please enter your partner's name and e-mail address

Partner's name

Partner's E-mail

Information regarding referrals and recommendations

Have you been send to me via referral or recommendation?

Yes

Who recommended or referred you to me?

Availability for sessions

Please give me information here about your availability to come to sessions. If you are interested in a service where there are will be more than one person present, the following questions apply to all persons involved.

I plan to attend sessions primarily

In person at your office

Online

In person and online as required

General availability for sessions

Anytime, I am flexible

There are certain days or times that are best for me

It varies, but I can come during your office hours

I can only come to sessions after 4 p.m.

Times that are possible for you. Please select all that apply.

Unfortunately owing to the high demand for sessions at this time, I can only offer sessions after 4 p.m. on an infrequent basis.

Session frequency

Frequency at which you would like to visit sessions.

Note: Psychotherapy research indicates that shorter session intervals (every 1-2 weeks) are beneficial for successful therapy outcomes. For coaching and supervision, intervals can be longer, depending on the topic.

You have indicated that you are only available for sessions after 4 p.m. which I can unfortunately only offer on an infrequent basis owing to the high demand for this time. Please consider this when selecting the option below.

If it is difficult for you to make it to my office regularly, please remember that I do offer sessions online in order to help here.

I/we are would like to come to sessions at a frequency as follows:

I only want a one-off consultation

Weekly

Every TWO weeks

Every THREE weeks

Monthly

As often or as little as necessary

Additional information about your availability

I am currently not able to offer weekly sessions after 4 p.m. Please revise your answers above.

I am currently not able to offer sessions every two weeks after 4 p.m. Please revise your answers above.

What you would like my help with

I consent to have this website store my submitted information which is required for the provision of mental health services.

Personal data

Information regarding referrals and recommendations

Availability for sessions

Session frequency