Intake Form Raja Psychologie

Name *

1. Describe your problems or symptoms in your own words. *

(e.g., feelings of sadness, anxiety, difficulty sleeping, low energy)

2. Since when have you been experiencing these problems or symptoms? *

(e.g., for the past three months, since childhood, after a specific event)

3. How do you cope with these challenges? What resources or sources of support do you have? *

(e.g., talking to friends or family, exercise, meditation, professional help)

4. What do you do yourself to reduce the symptoms? What helps? What did you used to do that you no longer do now? *

(e.g., practicing relaxation techniques, hobbies, social activities)

5. What is your own explanation? What do you think is going on? *

(e.g., stress from work, relationship problems, health issues)

6. How can we support you? *

(e.g., help managing anxiety, improving sleep, coping strategies)

7. Can you describe what your daily life looks like? *

(e.g., daily routine, social activities, responsibilities)

8. What is your current work situation? *

(e.g., full-time, part-time, unemployed, student, retired)

9. What is your current living situation? *

(e.g., living alone, with family, with roommates, in assisted living)

10. Are you satisfied with your current living situation and lifestyle? Please explain. *

(e.g., I feel comfortable and supported / I feel isolated or stressed)

11. (If you are in a relationship:) How long have you been with your current partner (and, if applicable, how long have you been married)? What are you satisfied or less satisfied with in your relationship? *

(e.g., we’ve been together for 5 years, married for 2 years; I appreciate our communication but struggle with conflicts)

12. (If you have a partner and/or children:) Please provide some information about your partner and/or children. *

(e.g., number of children, ages, any special circumstances)

13. Have there been any other significant relationships before (your current one)? *

(e.g., long-term relationships, marriages, or important partnerships)

14. What do you consider to be your personal strengths? *

(e.g., patience, creativity, resilience)

15. What do you consider to be your personal challenges or areas for growth? *

(e.g., tendency to worry, difficulty saying no, impatience)

16. Can you describe the composition of your family of origin? *

(e.g., two parents, one sibling, extended family nearby)

17. What were you like as a child? How did you experience your upbringing? *

(e.g., shy and quiet / outgoing and adventurous; supportive family / strict upbringing)

18. Can you describe the atmosphere in your parental home? *

(e.g., warm and loving, tense, or chaotic)

19. What kind of man was your father? How was your relationship with him in the past? How is your relationship with him now *

(e.g., caring and supportive; distant; now good friends)

20. What kind of woman is/was your mother? How was your relationship with her in the past? How is your relationship with her now? *

(e.g., strict but loving; close relationship; now less contact)

21. How is/was the relationship between your parents? How is their relationship now? *

(e.g., supportive partnership; divorced; currently on good terms)

22. How is/was your relationship with your brothers and sisters? *

(e.g., close and supportive; distant; conflicted)

23. Are you religious or do you have another form of spiritual belief? If so, how does this play a role in your life? *

(e.g., active church member; personal spirituality; no religious belief)

24. Have any significant (positive or negative) events occurred during your life? *

(e.g., loss of a loved one, major illness, achievements)

25. Can you describe your social network? *

(e.g., close friends, family support, community involvement)

26. What brings you joy or inspires you? *

(e.g., hobbies, nature, helping others)

27. What hobbies do you have, and how do you usually spend your free time? *

(e.g., reading, sports, gardening)

28. Would you say you are a good sleeper? *

(e.g., I sleep through the night / I have trouble falling asleep)

29. Are you currently taking any medication? *

(e.g., antidepressants, blood pressure medication)

30. Do you smoke or consume alcohol? Do you use any recreational drugs? *

(e.g., occasional drinking, no smoking, no drug use)

31. What does relaxation mean to you? *

(e.g., quiet time, meditation, hobbies)

32. Do you have any questions or concerns regarding sexuality? *

(e.g., difficulties, questions about orientation, intimacy)

33. Are you receiving or seeking any other forms of help or therapy besides Raja Psychologie? *

(e.g., counseling, medication, alternative therapies)

34. Are you currently experiencing or have you ever experienced burnout or excessive stress? *

(e.g., work-related burnout, stress from personal life)

35. Are you currently experiencing or have you ever experienced phobias and/or panic or anxiety attacks? *

(e.g., fear of heights, panic attacks)

36. Are you currently experiencing or have you ever experienced other psychological complaints or psychologically traumatic events in the (distant) past? *

(e.g., depression, trauma, PTSD)

37. Have there been any psychological problems in your family, such as with parents, grandparents, uncles, or aunts? If yes, what and with whom? *

(e.g., depression in mother, suicide in uncle)

38. Is there anything important you think is worth mentioning? Are there any complaints, problems, or special circumstances that have not yet been asked about?

(e.g., recent changes in life, other concerns)

Healthcare agreement *

Agreed
Not agreed

At the beginning and end of the treatment, Raja Psychology informs the general practitioner in writing. If necessary, the psychologist consults with the general practitioner. This exchange of information is strictly confidential and falls under medical professional confidentiality.

Declaration of consent *

Agreed
Not agreed

When invoicing, the care provider shares the following information with the client’s health insurer: • the main DSM category; • the basic mental healthcare profile; • the selected type of care request.

No-show policy read and agreed to *

Agreed
Not agreed

An appointment can always be canceled or rescheduled. During office hours, this can be done by phone, WhatsApp, or email; outside office hours, please use email. Appointments can be canceled free of charge up to 48 hours in advance. If you cancel within 48 hours before the appointment, the consultation will be charged.

Seen and agreed: *

Agreed
Not agreed

By submitting this form, you agree to our Terms and Conditions and Privacy Policy.

Intake Form Raja Psychologie

Raja Psychologie

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