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