Gestalt Therapy International

A community of dialogue

Programs around the world

Facilitating authentic living & working

Career coaching Client Intake Form

New clients must fill out this form.

All information is strictly confidential. We do not, under any circumstances, give your information out to any 3rd party.

Client details

Fields marked in bold are needed.

 

 

 

First Name*

 

 

Last Name*

 

 

Email*

 

 

Contact phone number*

 

 

Home phone

 

 

Work phone

 

 

City*

 

 

Address*

 

 

State*

 

 

Postcode*

 

 

Country*

 

 

Date of Birth*

 

 

Skype name

 

 

Notes - and how you came to know about us*

 

Contact in case of emergency

 

Emergency contact name*

 

 

Emergency contact phone*

 

Agreement and completion

 

Check to indicate agreement to having read and understood the disclosure statement*

 

Yes, I have read, understand and agree to the Informed Consent statement, including the cancellation policy and the refund policy. I understand the fee is $750 for the session.

No, I do not agree

 

Insert todays date*

 

 

 

Please answer the following question:

 

 

 

3 + 1 =