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Registration for psychotherapy / coaching

Personal Details
(This question is mandatory)
Title, first name, last name
e.g. Dr. Michael Smith
(This question is mandatory)
Sex
(This question is mandatory)
Age
Please note that I only work with individuals 18 years old and over
(This question is mandatory)
E-Mail
(This question is mandatory)
Telephone number

I may need to contact you for the purposed of (re-arranging) appointments or for administrative purposes. Please enter a mobile phone number here if you have one.

Please enter international dialing codes in the format 0043 ......

How can I help you?
(This question is mandatory)
Service you are interested in
(This question is mandatory)
Reason for getting in touch
Please say a couple of sentences as to how/what I can help you with. This is important for me to be able to evaluate if I have the correct expertise and capacity to provide you with the quality of service you require. 
Were you referred to me by someone? If so, by whom?  
Name of doctor / psychologist / friend / acquaintance who referred you.
Availability for therapy/coaching

Regular availability for psychotherapy/coaching is essential in order to maintain the quality of the service I provide. Please provide details here as to your availability. Please note that I work in 75 - 90 minute blocks. You can find information about costs here.

(This question is mandatory)
Can you regularly reserve a fixed time for therapy/coaching?
e.g. Mondays from 15:00 - 16:30
Days of the week on which you are available for therapy/coaching
Monday
Tuesday
Wednesay
Thursday
Friday
I need to know this in order to be able to see if I have the capacity to accommodate you. Please note, the more flexible you are able to be, the more likely I will be able to offer you a place. 
(This question is mandatory)
Please provide details of your shift working hours here
Please provide details here of any specific days/times you are (not) available for an initial consultation 

e.g. I am out of the country between 01.02.19 - 28.02.19;

I can do the 1st, 8th and 15th of February but not the 22nd. 

(This question is mandatory)
Do you have regular absences that will affect your availability for therapy/coaching?

e.g. business trips abroad; private trips to your country of origin

I need to know this as we will need to consider the impact of this on the therapy/coaching process and how we best can deal with it, e.g. via Skype sessions when you are abroad. 

Confirm and send
(This question is mandatory)

I have read and am in agreement with the costs, terms, and conditions of the services here