Personal informations – Daniela Rocha IJzerman

In case you are interested in starting individual or couples therapy with me, please take a few minutes to fill out this intake form. Therapy is a collaborative process between client and therapist. For the therapist to be able to offer a secure environment, the client and the therapist have to have the same goals. Before booking a first session with me, I would like to have more information about you. For this reason, if you are interested in starting a therapy with me, I ask you to fill out the intake form below. I will review your information and answer you within one week to book a phone call. The first phone call (free of charge) will consist of a 15-minute conversation where we can both ask some clarifications.

In case you don't feel comfortable submitting the form online, please add more information in the previous information text block.

Alternatively, you can use the 15-minute phone call to complete your Intake Form over the phone with me.

As the client-therapist relationship is highly personal, it is possible that the intake reveals that I am not the best therapist to help you. In that case, I will do my best to refer you to a better suited therapist.
If for some reason I am away and unable to schedule our phone call within a week you will receive an automatic reply email notifying the period in which I will be absent. You can then count that I should take one week from that date of my return to revise your intake form and contact you.

Personal information

Name:

Date of birth

Highest level of education

Occupation

Has your partner expressed an interest in coming with you?

Yes
No

Partner's name (if couples therapy)

Partner's date of birth (if couples therapy)

Contact information

Phone

Email

Address

Street Address Street Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who referred you or how did you get to know about my work?

Clinical information

Type of therapy that you are interested:

Online Individual Therapy
In-person Individual Therapy
Online Couples Therapy
In-person Couples Therapy

Briefly describe some the concerns you would like to address in therapy

Are there any concerns regarding your physical safety and the way you are feeling that you think I should know?

Yes
No

If yes, please describe your concerns

If you marked to be interested in in-person sessions (exclusively in-person or one time or occasionally in-person), please indicate which location are you interested in

Grenoble - possible on a weekly basis
Annecy - possible on a weekly basis
Lyon - possible once a month

What is your availability for appointment times (if you are not on Central European Time, please specify below which time zone you are considering here)* (e.g: Monday 13:00-16:00, Tuesday and Thursday from 9:00-11:00)?

What is your availability for the first 15-minute call (if you are not on Central European Time, please specify below which time zone you are considering here)* (e.g: Monday 13:00-16:00, Tuesday and Thursday from 9:00-11:00)?

INTAKE FORM

Personal information

Contact information

Clinical information

My availability is from Monday to Friday from 9:00 until 18:00 (Central European Time)