Form for Your professional and confidential psychotherapy session via E-Mail The method of payment will be clarified with You in a personal E-Mail exchange! Strict confidentiality is garanteed for the whole counseling and treatment process! Age: You are: single married living with a partner living with your parents widowed divorced Date: You must not answer the following questions. However, any answers would be of great help to me to answer to your request in a more profound, comprehensive, and qualified way! How do you experience your problems? a) psychologically b) bodily c) iin the relationship with your partner d) in the relationship with your friends e) in your profession/ in school / in your education or training Have you already recieved psychotherapeutic or psychiatric treatment? Do you sometimes or frequently think of suicide? Have you ever tried to commit suicide? IF YES, HOW? Please answer the foloowing questions! Otherwise I shall not be able to respond to your request. Please describe your problem and pose your questions! There are 4 large pages to write in! Within three days you will get my professional answer via E-Mail! And now one more question concerning your present life and about your visions about your future. This can be of help to me to find better answers to your problem. How do you live at present and how would you like to live? Wie werden Sie Ihre professionelle E-Mail Therapie bezahlen? The method of payment will be clarified with You in a personal E-Mail exchange! Strict confidentiality is garanteed for the whole counseling and treatment process!

If You don´t want to send the form:

Copyright © 1997 Andreas v.Wallenberg Pachaly. Alle Rechte vorbehalten.
Revised July 23d, 1999.