Intake form

Request for a therapy space. Fields marked with * are required.

Please review the highlighted fields before continuing.

Personal information

Full name *

Age * Contact email *

Country and city you are reaching out from * Nationality *

Social and work situation

What is your current work situation? *

Who do you currently live with? * You can choose more than one.

Do you have close, trusted people you can talk to when you need it? *

Reason for consultation

What brings you to look for a space at this time? * Briefly tell us what is going on or what you would like to work on in therapy.

Psychological and psychiatric history

Have you had previous psychological treatment? *

If you have had or currently have psychological treatment, can you tell us a bit more? Approximate duration, approach if you know it, reason, how it went. Have you received or are you receiving psychiatric care? *

Do you take or have you taken psychiatric medication? *

If so, which medication? Who prescribed it? Are you still seeing that professional? Have you had psychiatric or psychological hospitalizations? *

If you want, tell us in what context and when it was: Is there or has there been substance use (alcohol, drugs or others) you consider relevant to mention? *

You can tell us whatever you like about this:

Medical history

Is there anything about your physical health you consider relevant to mention? Chronic illnesses, hospitalizations, surgeries, current health situations.

Availability and format

Which days are you available for sessions? * You can choose more than one.

What time of day do you prefer? (your local time) * You can choose more than one.

Preferred format? *

Payment method

Which payment method do you have available? * You can choose more than one.

Please specify the other payment method *

Additional information

Would you like to add anything else you consider important?

Confidentiality and privacy. The information you share in this form is strictly confidential and will be received solely by the network coordinator, Vanesa Capovilla, Licensed Psychologist (License No. 58032), for the purpose of guiding your intake and referring you to the most suitable professional. Your data is not shared with third parties outside the network nor used for commercial purposes, and it is handled under professional confidentiality and applicable data protection law. By submitting this form, you consent to the coordination team contacting you and managing your request for a therapy space.

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