Intake form

Name *

Email address *

What is your primary reason for seeking therapy?

Please select at least one option.

Anxiety

Depression

Trauma

Stress Management

Relationship Issues

Have you previously received any form of psychological therapy?

If yes, please specify the type of therapy you received.

What specific goals do you hope to achieve through therapy?

How did you hear about emilia schwertner pracowania psychologiczna sisyphos minds?

Please indicate your preferred method of contact.

Do you have any specific preferences regarding the therapist's gender?

What days of the week are you generally available for appointments?

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What time of day do you prefer for appointments?

Please select at least one option.

Morning

Afternoon

Evening

Do you have any medical conditions or medications that we should be aware of?

Additional questions or comments

Emilia Schwertner Pracowania Psychologiczna Sisyphos Minds