Intake form

You have made your first appointment for an individual session.
Welcome!

Do you want to answer the questionnaire below at least two days before the intake?

The purpose of this questionnaire is to obtain information about you, your complaints and personal background. This information is the start for the intake interview. During the intake we will elaborate on your question, theme or problem and we agree on the follow-up process.

All information you provide is covered by professional secrecy and privacy protection law. Your data will therefore be treated in strict confidence. The website is of course also secured, you can see that through the lock for the website name.

Your information will never be provided to third parties. See also the Privacy statement (only in Dutch).

If you have any questions, please contact me.

See you soon!

Sincerely,
Floor Slagter

Intake

Name *

Address (street/house number/zip code/city) *

E-Mail *

Phone number *

Date of birth *

1. What is your request for help / theme / problem?

2. Describe your physical and / or emotional complaints.

3. Have you followed therapy or counseling elsewhere? How long and where?

4. Are there specific illnesses or complaints in the family that are important?

5. Do you drink alcohol? How much on a day?

6. Do you use medication? Which and in what dosage?

7. Briefly say something about your relationship with your family as a child
a. With your father
b. With your mother
c. With your brother (s) / sister (s)

8. How is your relationship with your partner or are you single now?

9. Do you have children? How is your relationship with them?

10. What is your background in education and work?

11. Do you want to add something that has not been requested yet?

I hereby declare that I have answered the questions truthfully and I consent to my data being collected.

Intake form

Intake

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