Initial Intake Form Initial Intake FormΔ First NameLast NameEmail AddressPhone NumberCity, Country🔒 Crucial Safety CheckpointsYour safety and privacy are paramount. Please specify how we may contact you.Can I leave a voicemail at this phone number? Yes, it is safe to leave a voicemail. No, do not leave a voicemail under any circumstances.Can I send emails to this address? Yes, it is safe to email me. No, please only communicate via phone call.Is it safe for me to mention my title (“Relationship Counselor” / “Trauma Consultant”) if someone else answers? Yes, it is safe. No, please use a generic name or say it is a personal/discreet call.Service DetailsSelect the service you wish to discuss during our consultation.Service Requested Individual Trauma Consultation (€150 / 60-mins) Companion, Couple, or Family Counseling (€250 / 75-mins) Unsure / Let’s discuss during the callWhat is bringing you to counseling right now? (Optional)Submit Form