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Application

At GEMMA, counselling is intended to be a cooperative therapeutic process.

I approach my clients with respect and empathy and see them as individuals with unique needs based on their current situations. I would like to help you reach your goals and find the necessary skills and tools within yourself. For this reason, certain information is helpful for me at the beginning of our relationship.

This is why I request that you fill out this short self-declaration. Feel free to limit your answers to keywords as needed. This will form the basis of our initial conversation, during which we can address any questions you may have and that you perhaps are unable to write about in detail at this time.

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Self-disclosure report:

Personal details

I will contact you by phone in the next two to three weeks to discuss your questions for me and to better prepare myself for our first session. Please let me know the date and time you are available and the phone number at which I can reach you directly.

Please provide your full name
Please provide your date of birth
Please provide your email
Please provide your number
1.

Current situation and symptoms

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2.

Personal history

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3.

Resources

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4.

Goals/vision

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5.

Improvements/breakthroughs

Between now and our first session, please be aware of any minor or major improvements or breakthroughs you experience.

6.

Medical history

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Please provide your height
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Gynaecological history

If this section is not applicable to you, just enter "no"

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Family history
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Suicidal tendencies
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Terms & Conditions


Cancellation:

I declare that I have been informed of and agree to the following:
A cancellation period of 24 hours shall apply. In the event that a consultation is not cancelled in advance of the 24 hour cancellation period, GEMMA Institute will be entitled to issue an invoice to the client for the full consultation amount.

Acceptance is required.


Medical Testing:

Please be aware that every psychological change could have an organic cause. For this reason, I ask that you speak to your primary care physician before starting psychotherapy in order to exclude any possible organic cause. The following tests should be carried out: Blood testing with a partial blood count, electrolytes, thyroid hormones (TSH, fT3, fT4), kidney and liver values, blood glucose levels, creatine kinase, blood coagulation, and possibly vitamin D3, vitamin B12, and folic acid. Furthermore, an Electrocardiography (EKG) and imaging of the skull (cranial CT scan or cranial MRI) are to be performed.

Acceptance is required.


Privacy Policy:
Acceptance is required.


Video recording (optional):