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Intake

Thanks for your help!

Please help me help you by filling on the intake forms here. These forms are used for assessment and preparation for our initial consultation. 

There are 3 forms that I would like to ask both you are your partner to fill out without conferring with one another on questions relating to relationship quality or the perceived intensity of mental health symptoms:

  1. Your contact details. If you were the person who contacted me initially and have already filled out the initial contact form with your contact information, then you can leave this form out.
  2. Background and relationship. 
  3. Mental health assessment.
EN – Terms, personal info

Before filling out the form below to request an initial consultation, please read through the following information:

The terms and conditions of my services, inluding:

 

Please note that,

  • An initial consultation is charged at the standard price of a regular session
  • I do not offer sessions in the evenings after 5:30pm or at weekends
  • I only work with clients over 17 years of age
 
 

e.g. Dear , 

e.g. Dear , 

Please enter your date of birth below. Tip: the year can be changed by clicking on it and using the two arrows that appear in order to adjust the value.

Please enter the names of all family members who will be attending sessions and their e-mail addresses. You can add further family members by clicking the plus symbol to the right of the row.

 

Please enter your partner’s name and e-mail address

Information regarding referrals and recommendations

Availability for sessions

Please give me information here about your availability to come to sessions. If you are interested in a service where there are will be more than one person present, the following questions apply to all persons involved.

Unfortunately owing to the high demand for sessions at this time, I can only offer  sessions after 4 p.m. on an infrequent basis. 

Session frequency

Frequency at which you would like to visit sessions.

Note: Psychotherapy research indicates that shorter session intervals (every 1-2 weeks)  are beneficial for successful therapy outcomes. For coaching and supervision, intervals can be longer, depending on the topic. 

You have indicated that you are only available for sessions after 4 p.m. which I can unfortunately only offer on an infrequent basis owing to the high demand for this time.  Please consider this when selecting the option below.

If it is difficult for you to make it to my office regularly, please remember that I do offer sessions online in order to help here. 

I am currently not able to offer weekly sessions after 4 p.m. Please revise your answers above.

I am currently not able to offer sessions every two weeks after 4 p.m. Please revise your answers above.

EN – Intake Form (background information)

Your Name

Please enter the name of your partner who you will be come to sessions with

Demographic information

Relationship information

Information about your deceased partner

Please enter details (name and date of birth) of any children you have below. Use the “plus” symbol on the right-hand side to add a child. 

Marriage history

EN – Mental health assessment

Adjust the slider below to mark your agreement with the following statement on a scale of 0 to 10 where 10 means you absolutely agree and 0 means you absolutely disagree.

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Mental health assessment

Adjust the sliders below to mark the INTENSITY of how you are experiencing the following problem areas on a scale of 0 to 10,  where 0 is an absence of the problem and 10 is the maximum intensity.

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GAF SCORING

GAF 100-91 = PASS

Hervorragende Leistungsfähigkeit in einem breiten Spektrum von Aktivitäten; Schwierigkeiten im Leben scheinen nie außer Kontrolle zu geraten; keine Symptome.

 

Life under control, no mental health issues to speak of, problems are every day in nature.

Resources available: wide range of activities; self-agency; satisfaction with life

Recommendation coaching for career, life, relationship. Couples therapy, family therapy. Redirect to relevant form. 

GAF 90-81 = PASS

Keine oder nur minimale Symptome (z.B. leicht Angst vor einer Prüfung), gute Leistungsfähigkeit in allen Gebieten, interessiert und eingebunden in ein breites Spektrum von Aktivitäten, sozial effektiv im Verhalten, im allgemein zufrieden mit dem Leben, übliche Alltagsprobleme oder -sorgen (z.B. nur gelegentlicher Streit mit einem Familienmitglied).

1-2

 

GAF 80-71 = PASS

Wenn Symptome vorliegen, sind dies vorübergehende oder zu erwartende Reaktionen auf psychosoziale Belastungsfaktoren (z.B. Konzentrationsschwierigkeiten nach einem Familienstreit); höchstens leichte Beeinträchtigung der sozialen beruflichen und schulischen Leistungsfähigkeit (z. B. zeitweises Zurückbleiben in der Schule).

3-4

GAF 70-61 = PASS

Einige leichte Symptome (z.B. depressive Stimmung oder leichte Schlaflosigkeit ODER einige leichte Schwierigkeiten hinsichtlich der sozialen, beruflichen oder schulischen Leistungsfähigkeit (z. B. gelegentliches Schuleschwänzen oder Diebstahl im Haushalt), aber im allgemeinen relativ gute Leistungsfähigkeit, hat einige wichtige zwischenmenschliche Beziehungen.

5-6

GAF 60-51 = PASS

Mäßig ausgeprägte Symptome (z.B. Affektverflachung, weitschweifige Sprache, gelegentliche Panikattacken) ODER mäßig ausgeprägte Schwierigkeiten bezüglich der sozialen, beruflichen oder schulischen Leistungsfähigkeit (z. B wenige Freunde, Konflikte mit Arbeitskollegen, Schulkameraden oder Bezugspersonen).

7-8

GAF 50-41 = PASS

Ernste Symptome (z. B Suizidgedanken, schwere Zwangsrituale, häufige Ladendiebstähle) ODER eine Beeinträchtigung der sozialen, beruflichen und schulischen Leistungsfähigkeit (z. B. keine Freunde, Unfähigkeit, eine Arbeitsstelle zu behalten).

9-10

OR Suicidal ideation, regular criminality

GAF 40-01 – WARNING!!

Starke psychiatrische Symptome vorhanden. Ambulante Behandlung nicht mehr möglich