Systemic Therapy Client Form — Systemic Therapy

Client Registration form

Systemic Therapy with Renata Costeski Bauer

Hello and a warm welcome!

Congratulations on choosing to embark on the therapeutic journey—a significant step in your life. Regardless of the distance or the size of the step, what matters is that you've taken action and found yourself in a different place, closer to your goals.

Before we dive into our process, let's get to know a bit about you.

Rest assured, all information shared will be kept confidential and private. The following fields are optional and designed to enhance our sessions. Feel free to skip any you're not comfortable answering.

Wishing you a joyful and transformative journey ahead!

Full Name

First Name

Last Name

Date of Birth:

YYYY

Country and city of birth

Full Name of Mother (biological and/or Adoptive)

Full Name of Father (biological and/or Adoptive)

Country of birth of parents (biological and/or Adoptive)

Names of Siblings and information about any known miscarriages your mother may have had

Current and previous occupations

Medical and mental health history, including previous diagnoses, current medications, and history of prior treatments

Next of kin (Relanship)

Name and Phone Number:

Reason for seeking this process and how it affects your daily life

Significant relationships, including past and current relationships

History of traumatic events in life and family dynamics

How was our chat? What did you take away from our first meeting?

What do you expect from this process?

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Client Registration form

Systemic Therapy with Renata Costeski Bauer

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