Gestalt Therapy International

A community of dialogue

Programs around the world

Facilitating authentic living & working

Supervisee Intake Form

New supervisees 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*






Contact phone number*



Home phone



Work phone


















Date of Birth*



Skype name



Notes - and how you found out about us*



Full Name



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. I understand the fee is $220 per hour.

No, I do not agree


Insert todays date*




Please answer the following question:




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