Individual Help Home E Online appointment E Individual HelpIndividual help Name Name First First Last Last Email * Phone Have you ever benefited from counseling / psychotherapy before? * YesNo What determined you to look for help today? * I've been feeling depressed / anxiousI feel out of my depth and / or overwhelmed by a situationI can't function to my full capacityI feel I have no purposeI suffered a lossI suffered a traumaIt was recommended to me by a doctorI want to work on some of my abilities but I don't know where to startI received a diagnosisOther reason How often have you felt a low interest in doing anything? * NeverA few daysMore than half of the timeAlmost every day Do you experience any kind of chronic pain? * YesNo Are you taking any medication? * YesNo How would you assess your sleep? * GoodAcceptableNeeds improvement How would you assess your meal routine? * GoodAcceptableNeeds improvement How would you assess your physical health? * GoodMediumPoor How old are you? What's your gender? * MaleFemaleOther / Rather not mention What is your marital status? * SingleIn a relationshipMarriedDivorcedWidow / widowerOther / Rather not mention Where do you live? What is your preferred language for therapy? * EnglishRomanian What is your preferred location for therapy? * OnlineFace to face – Unirii officeFace to face – Grozăvești office What are your expectations from your therapist? * Be a good listenerExplore my past togetherTeach me new abilitiesHelp me change my beliefsAssign me therapeutical tasksGuide me to my own objectivesBe proactiveOtherI don't know yet What therapist do you prefer? * MaleFemaleNot important How did you hear about us? * Recommended by someoneFriends / FamilyGoogleFacebookInstagramLinkedInOther Informed Consent * I agree with Veltio’s Terms and Conditions reCAPTCHA If you are human, leave this field blank. Send
