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Application (Individuals)

At GEMMA, counselling is intended to be a cooperative therapeutic process.

I approach my clients with respect and empathy and see them as individuals with unique needs based on their current situations. I would like to help you reach your goals and find the necessary skills and tools within yourself. For this reason, certain information is helpful for me at the beginning of our relationship.

This is why I request that you fill out this short self-declaration. Feel free to limit your answers to keywords as needed. This will form the basis of our initial conversation, during which we can address any questions you may have and that you perhaps are unable to write about in detail at this time.


Self-disclosure report

Please note

There are currently no free places for individual therapy. You are welcome to fill out the self- disclosure report anyway and we will put you on the waiting list. However, be aware that due to the enormous demand for psychotherapy, it can sometimes take up to one and a half years before we can offer you a therapy place.

Personal Details

I will contact you by phone in the next two to three weeks to discuss your questions for me and to better prepare myself for our first session. Please let me know the date and time you are available and the phone number at which I can reach you directly.

1. Current situation and symptoms


Please tell me anything you think I should know before our first session so that I am up to date on the current situation and so that I can best support you.


In your opinion, what led to the current situation?


Are your symptoms impacting your everyday life? If so, which?


Have you been able to successfully limit or control any of your symptoms already? If so, how?

2. Personal history


What were the major events in your life so far?


What is your relationship like with your family of origin?


How would you assess your professional career?


Have you had any previous experience with inpatient or outpatient therapy?

3. Resources


What do you not want to change during outpatient therapy because you feel that it is valuable and helpful?


What do you like about yourself? What brings you joy? What gives you strength?


What approaches have not been successful or had a negative effect?

4. Goals/vision


What would you like to achieve with therapy? What are your expectations for me?


Do you have any fears or worries about therapy?


What would you like to use our sessions for?


How many sessions do you think we will be needing?

5. Medical history




Do you have any chronic illnesses? Have you had any operations? (Please specify Illness/operations & when they occurred)


What medications are you currently taking? (Please specify medication, dosage & start date)


Do you smoke? If so, how much?


Do you drink alcohol? If yes, how much and how often?


Do you have experience with the consumption of illegal drugs? Which? How much? When did you start?


Do you have any allergies?


Have you ever had a preventive medical check-up? If so, when was your last one? What were the results of your last check-up/preventive procedure? (e.g. colonoscopy, gynaecological check-up, urological check-up)


Are your vaccinations currently up to date?

Gynaecological history

If this section does not apply to you, simply enter 'No'.


Have you ever been pregnant?


Have you ever given birth? If so, how was your experience giving birth?


Have you ever had a miscarriage or an abortion?


Which form(s) of contraception do you use


When was your first menstrual cycle?


When was your most recent menstrual cycle?

Family history

Is there a history of illness in your family? (high blood pressure, cardiovascular diseases, cancer, addiction, mental illness, etc.)


Parents - Year of birth & Illness(es)


Grandparents - Year of birth & Illness(es)


Siblings - Year of birth & Illness(es)


Children - Year of birth & Illness(es)

Suicidal tendencies


Have you ever experienced or are you currently experiencing suicidal thoughts?


Have you ever planned or taken action towards a suicide attempt? If so, when?

6. Improvements/breakthroughs

Between now and our first session, please be aware of any minor or major improvements or breakthroughs you experience.

7. Terms & Conditions


I declare that I have been informed of and agree to the following:

A cancellation period of 24 hours shall apply. In the event that a consultation is not cancelled in advance of the 24 hour cancellation period, GEMMA Institute will be entitled to issue an invoice to the client for the full consultation amount.

Medical Testing

Please be aware that every psychological change could have an organic cause. For this reason, I ask that you speak to your primary care physician before starting psychotherapy in order to exclude any possible organic cause. The following tests should be carried out: Blood testing with a partial blood count, electrolytes, thyroid hormones (TSH, fT3, fT4), kidney and liver values, blood glucose levels, creatine kinase, blood coagulation, and possibly vitamin D3, vitamin B12, and folic acid. Furthermore, an Electrocardiography (EKG) and imaging of the skull (cranial CT scan or cranial MRI) are to be performed.

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