Konektis - Registration Form

Welcome to the registration form of Konektis Practice House.

Based on your answers, we will determine which professional is best suited to address your needs. It will be this professional who will then contact you to answer any further questions and, if desired, schedule an initial appointment. We handle your answers with care and utmost respect for your story and privacy.

Warm regards,

Werner, Cindy & Chayenne (www.konektis.be)

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Age *
Required
Preferred form of therapy
 *
Required

Please briefly describe the reasons why you are seeking a therapist/sexologist.

 *

Do you have any preferences regarding the professional?

For example:

Gender preference (male, female, non-binary)
Expertise in specific topics
Explicit preference for a specific professional: Werner, Cindy, Chayenne

What are the available appointment times?

 *
Required

Where would you like to have the appointment take place?

Appointments can also be arranged on location in consultation (e.g., if you have mobility issues, reside in a nursing home, etc.). Please specify in the "anders" (= 'other') field if applicable.

 *
Required

We sincerely thank you for taking the time and energy to fill out this form. We receive it with the utmost respect for your story and privacy. Please let us know below how we can best contact you.

Please provide your first name (or names), as well as your phone number and/or email address.

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