Initial Intake

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone* This field is required.(The phone number will be used to assign you to a Telegram group. You will not be receiving any calls. Please use the same phone number that you have used to register on Telegram. If you’re not sure, please open the app and double check. This is very important – otherwise, I will be able to add you to the group)
Please enter a valid phone number.
4
How long were you in this relationship?* This field is required.
5
Who initiated the breakup?* This field is required.
6
Is this your first break-up? If not, how does it compare to the previous ones? (More/less painful, etc.)* This field is required.
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7
What is your main emotional challenge that you’re trying to overcome with this therapy? (i.e. forget him, not feel guilty, not blame myself, etc.)* This field is required.
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Ok
8
What is your main emotion after this breakup (i.e getting depressed, being unsocial/clamming up, numb, etc.)* This field is required.
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Ok
9
Briefly describe what happened* This field is required.
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Should be Empty: