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Note A red asterisk(*) following the entryfield means that input is mandatory.
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First Name and Surname(*)
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Home Address(*)
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Post Code(*)
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City / Town / Village(*)
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Country(*)
Ongeldige invoer
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Phonenumber (home/work)(*)
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E-mail Address(*)
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Gender(*)
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Date of Birth (dd-mm-yyyy)(*)
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Marital Status(*)
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Number of Children(*)
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The following fields request your personal score. You can calculate this score in the book "Rediscovering the True Self" (p 255) and/or online with the Personal Defense Profile Test on this website.
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Score Fear(*)
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Score PD(*)
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Score FP(*)
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Score FH(*)
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Score DoN(*)
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Education / Qualifications(*)
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Profession(*)
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Why do you want to go into therapy?(*)
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Which PRI-books from Ingeborg Bosch have you read ?(*)
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Information from your childhood (family situation, your place in this family, and happenings and circumstances that you feel are relevant to this therapy)(*)
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More recent experiences that might be important(*)
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Use of tobacco, alcohol and drugs (If yes - how often, how much?)(*)
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Any other addictions (If yes - how often, how much?)(*)
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Use of medication (now and in the past)(*)
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Physical condition (physical complaints, diseases, disturbed eating or sleeping patterns)(*)
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Have you had help from mental health care professionals before? (if yes: in what form, when, how long, and what was the result?)(*)
Please enter a valid value for: history mental health care professionals
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Did you have any conflicts with a mental health care professional? (if yes what kind of conflict?)(*)
Please enter a valid value for: History conflicts with a mental health care professional
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Are any of the contra indications applicable?(*)
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Questions / remarks
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Herewith I confirm that through sending this therapy form, I have filled in the above information truthfully and agree with the .
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I Agree(*)
If you do not agree with the said conditions you cannot submit this form.
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