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Intake form

All information concerning you will remain confidential and will only be used in order to assign you a psychotherapist.

First name

Last name

E-mail address

Home telephone number (+xx yy zzzzzzz)

Office telephone number (+xx yy zzzzzzz)

Portable number (+xx yy zzzzzzz)

Language requested for your psychotherapy (please check one)

 French
 English
 Spanish

Type of psychotherapy requested (please check one)

 Individual
 Couples

Please specificy your time preferences for your sessions (mornings, afternoons, etc.)

Profession

Date of birth (month/day/year)

Marital status

You have been refered to our services by

Reasons to request a consultation (all subjects which apply to you)

 Self esteem
 Depression
 Addiction   Which type 
 Codependency
 Sexual problems, dysfunction
 Gender orientation
 Couple problems
 Eating disorder
 Grief
 Physical health
 Stress
 Anger management
 Anxiety
 Relationship with family of origin
 Career and work related issues
 Burnout
 Learning disabilities
 Interpersonal relations
 Other

Please describe briefly the reasons for your request and any other information which might help us address you to our psychotherapists

 I have read and accept the general conditions for on line psychotherapy sessions

Validation of your submital

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