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Methods & Approach
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My Path & History
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Methods & Approach
Research & Resources
Formats & Offerings
My Path & History
Costs & Contact
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DE

intake form

Intake Questionaire

Name

Please take your time in providing the following information. The questions are designed to help me begin to understand you so that our time together can be as productive as possible. All information provided is confidential.

Name(Required)

First Last

Have you previously received any type of mental health services?(Required)

no

psychotherapy

medication

hospitalisation

if yes, please specify

type of therapy, medication, treatment, duration etc.

Have you been diagnosed in the past?

Please list diagnose and year it was given

What motivates you to seek support now?(Required)

Briefly list your symptoms and your goals you want to work on.

Since when do you experience this?(Required)

several answers possible

1 month

6-12 months

at least 2 years

adolescence

childhood

What areas of your life have been affected because of this?(Required)

Are you currently experiencing overwhelming sadness, grief or depression?(Required)

no

yes

if yes, please specify

since when, how often, specific triggers, how do you cope

Are you currently experiencing anxiety, panic attacks or have any phobias?(Required)

no

yes

if yes, please specify

since when, how often, specific triggers, how do you cope

Please describe any major losses or traumas you have experienced(Required)

What significant life changes or stressful events have you experienced recently?(Required)

Family History

Where and how did you grow up?(Required)

Did you grow up in one place or did you move? If yes, how many times? Did you also move countries?

Who raised you?(Required)

Family members

please list your parents and siblings or other caretakers or members in your home while growing up.

Role

Relationship

Current Age (if deceased, age of Death)

Mother's occupation(Required)

Father's occupation(Required)

Have you been exposed to or experienced any of the following while growing up?

multiple answers possible

Alcohol/Substance Abuse

Anxiety

Depression

Domestic Violence

Sexual Abuse

Eating Disorders

Obesity

Obsessive Compulsive Disorder

Schizophrenia

Suicide Attempts

other diagnosed mental health condition

if yes, please specify

indicate the family members and their relationship to you

Which local support network did you have growing up?(Required)

multiple answers possible

none

partner

family

friends

neighbors

peers (sports, hobbies, communities)

spiritual/religous context

other

please specify

level of contact, people in other places, challenging relationships etc.

Relationship / Marriage

Please state your current relationship status(Required)

single

in a relationship

married

separated

divorced

widowed

remarried

please specify

since when

Please rate the relationship

If you have experienced recurring dynamics in your relationships, please specify:(Required)

If you know, which is your attachment style?(Required)

Do you have children?

no

unfulfilled wish

yes

Please list your children

please list your children and all pregnancies

Gender/Name

Other Parent

Relationship

Age (if deceased, age and year of Death)

Life Experiences

Have you experienced any of the following?

multiple answers possible

Bullying

Mobbing

Abuse

Violence

Discrimination

Adultism

Gaslighting

Shaming

Racism

Exclusion

other

if yes, please specify

Which local support network do you have currently?(Required)

multiple answers possible

none

partner

family

friends

neighbors

peers (sports, hobbies, communities)

spiritual/religous context

other

please specify

level of contact, people in other places, challenging relationships etc.

Physical Health

How would you rate your current physical health?

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Poor

Unsatisfactory

Satisfactory

Good

Very Good

If you are having problems, in which phase of sleep are you experiencing issues?

Falling asleep

Staying asleep

Awakening early

Sleep apnea

Please list any other specific sleep problems you are currently experiencing:

Are you currently experiencing any chronic pain?

no

yes

if yes, please specify

what and since when

How often per week do you exercise? What type?

Please describe CURRENT use of alcohol, cigarettes, and/or recreational drugs:

Please describe PREVIOUS use of alcohol, cigarettes, and/or recreational drugs:

Any other health related issues not listed above:

Additional Information

What do or did you enjoy about your work?

What do you experience as particularly stressful regarding your work?

What do you enjoy doing in your free time? What do you do to relax?

Do you consider yourself to be spiritual or religious? If so, please describe your faith or belief:

What do you consider to be some of your strengths?

If we were at the end of our work and you had achieved your goal, how would you feel?

Which is the greatest obstacle on your way there?

What do you consider to be some of your weakness?

What do you hope to get out of this work, what is your goal?

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Company

This field is for validation purposes and should be left unchanged.

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Name*

First Last

Email*

Message

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