Application for counselling

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OZ Centrum Terapeutických Služieb (CTS) provides professional support in the field of mental health to people who would not otherwise be able to access it themselves. If you are interested in our services, please fill in this application form. The information in it will help us find out whether our services are suitable for you. At the same time, it will allow us to select candidates for whom this type of support will be the most useful.

In case that CTS is unable to provide support for you through our counsellors, either for capacity reasons or due to the suitability of another type of support in your specific case, you will receive from us a recommendation for other mental health services available in the Slovak Republic.

All information provided in the questionnaire is confidential and is used solely for the purposes of OZ Centrum Terapeutických Služieb. Thank you for completing the questionnaire. Estimated time to complete it is 15 minutes.

Personal data

This data is collected mainly to facilitate our communication during the selection and counselling process and subsequently only in an anonymized form.

1. Name *

2. Surname *

3. E-mail *

4. Phone number *

5. Gender identity *

Man

Woman

Other:

6. Date of birth *

We provide our services to adults only, i.e. 18+ years.

7. Where in Slovakia would you like to use our services? *

Bratislava

Other:

8. Check the category which describes you the most: *

Working person (permanent/temporary contract, entrepreneurship ...)

Student

On maternity/parental leave

Not employed or not able to work

Retiree

Other:

9. Is online counselling acceptable for you? *

(via zoom, skype, whatsapp...)

Yes, I don't mind

Temporarly yes

Mostly no

Not at all

10. How did you find out about us? *

From the state authorities (City Hall of the Slovak Republic, local authority, etc.)

Recommendation from an expert (doctor, professional organizations, etc.)

Recommendation from our former client

Recommendation from a friend

Internet and media

Other:

Required

Financial situation

OZ CTS provides services that are financially funded and supported by volunteer work. To ensure that our services reach people who would not otherwise be able to afford quality mental health care, we ask you to carefully answer the following questions.

11. Why do you think you need funded mental health care? What is your financial situation? *

12. What is the average monthly income of your household? *

In the net amount - how much will actually come to your account

13. What are the average monthly costs of your household? *

14. Is another person involved in sharing the household costs with you? *

Yes

Other:

15. What amount of voluntary contribution per session is manageable for you? (recommended amount starts from 5 € per session) *

In total, you have an opportunity to complete 12 sessions spread over 3 - 9 months.

Description of your problem

In the following section, please briefly describe the topic that brought you here.

16. Please write us about your life situation and the problem that motivates you to seek mental health counseling.

17. When did you begin to feel the need for professional help? How long does your problem last?

18. Please rate the subjective severity of your problem, where 1 is not very serious and 10 is very serious, even critical

not very serious

critical

Clear selection

19. What specific improvement would you like to achieve through counselling? E.g. concerning relationships, lifestyle, level of stress experienced ....

Please, be specific.

20. Please describe your current background - people you can rely on and the environment in which you live.

Clear form

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