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Email
*
Your email
What is your main concern which makes you look up a psychologist/psychotherapist/coach?
*
Your answer
How long have you this problem/these issues?
0-5 years
5-10 years
>10 years
Clear selection
Have you worked with a psychotherapist/psychologist/psychiatrist before?
yes
no
Clear selection
If you have experience with psychotherapy: Do you remember what kind of therapy it was?
Behavioural therapy
Psychoanalysis
Depth Psychology
Other
Clear selection
How satisfied are you with the psycho-help you received?
not so much - was not helpful
1
2
3
4
5
very much - was very helpful
Clear selection
What do you hope for you will get/learn through the exchange and work with a "psycho-professional"?
Your answer
When is your birthday?
MM
/
DD
/
YYYY
Please tell me your full name and address. I need these details for the invoice production afterwards.
*
Your answer
Do you want to receive an invoice? I would send it through - either via WhatsApp or your mail address provided above.
Yes, I need/want an invoice!
No, thanks!
Clear selection
...please tell me your phone number (mine is: 017643428766) - so that we can text or send (mainly) organisational WhatsApp messages to each other:
*
Your answer
Thank you very much for your time and feedback/info provided! If you have questions/comments -- you can leave a note here:
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