PRI, live life from love, compassion and connection
Intensive therapy form
  1. Note A red asterisk(*) following the entryfield means that input is mandatory.
  2. First Name and Surname(*)
    Please enter a valid value for: First Name and Surname
  3. Home Address(*)
    Please enter a valid value for: Home Address
  4. Post Code(*)
    Please enter a valid value for: Post Code
  5. City / Town / Village(*)
    Please enter a valid value for: City / Town / Village
  6. Country(*)
    Ongeldige invoer
  7. Phonenumber (home/work)(*)
    Please enter a valid value for: Phonenumber (home/work)
  8. E-mail Address(*)
    Please enter a valid value for: E-mail Address
  9. Gender(*)
    Please enter a valid option for: Gender
  10. Date of Birth (dd-mm-yyyy)(*)
    Please enter a valid value for: Date of birth (dd-mm-yyyy)
  11. Marital Status(*)
    Please enter a valid value for: Marital Status
  12. Number of Children(*)
    Please enter a valid value for: Number of Children
  13. 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.
  14. Score Fear(*)
    Please enter a valid value for: Score Angst
  15. Score PD(*)
    Please enter a valid value for: Score PD
  16. Score FP(*)
    Please enter a valid value for: Score FP
  17. Score FH(*)
    Please enter a valid value for: Score FH
  18. Score DoN(*)
    Please enter a valid value for: Score DoN
  19. Education / Qualifications(*)
    Please enter a valid value for: Education / Qualifications
  20. Profession(*)
    Please enter a valid value for: Profession
  21. Why do you want to go into therapy?(*)
    Please enter a valid value for: Why do you want to go into therapy?
  22. Which PRI-books from Ingeborg Bosch have you read ?(*)
    Please enter a valid value for: Books red
  23. Information from your childhood (family situation, your place in this family, and happenings and circumstances that you feel are relevant to this therapy)(*)
    Please enter a valid value for: Information from your childhood.
  24. More recent experiences that might be important(*)
    Please enter a valid value for: recent experiences
  25. Use of tobacco, alcohol and drugs (If yes - how often, how much?)(*)
    Please enter a valid value for: Use of tobacco, alcohol and drugs
  26. Any other addictions (If yes - how often, how much?)(*)
    Please enter a valid value for: Other addictions
  27. Use of medication (now and in the past)(*)
    Please enter a valid value for: Use of medication
  28. Physical condition (physical complaints, diseases, disturbed eating or sleeping patterns)(*)
    Please enter a valid value for: Physical condition
  29. 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
  30. 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
  31. Are any of the contra indications applicable?(*)
    Please enter a valid value for: contra indications
  32. Questions / remarks
    Please enter a valid value for: Questions/remarks
  33. Herewith I confirm that through sending this therapy form, I have filled in the above information truthfully and agree with the proviso.
  34. I Agree(*)
    If you do not agree with the said conditions you cannot submit this form.