Gestalt Therapy International

A community of dialogue

Programs around the world

Facilitating authentic living & working

Client Intake Form

New clients must fill out this form. If you are a couple, enter information for each person as a separate submission, and list your partner's name on your form for cross referencing.

If client is a child, fill in all the details, and put parents name as cross reference in the relevant box.

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

Select fee



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