Application for psychological support

Виберіть мову у верхньому правому куті форми
Інформація, яку ви надасте в цій формі, є повністю конфіденційною, її побачить лише ваш координатор і передасть лише вашому терапевту.
Please confirm your email*
Your full name*

First NameLast Name
Phone Number*

Country CodePhone Number
Number for messengers

Country CodePhone Number
Current city and country of residence *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you requesting therapy for a child/teenager?*

YesNo
Please give your child's age
Health Information
How would you rate your mental health condition? *

1

2

3

4

5

6

7

8

9

10

1 is Very Poor, 10 is OK
Please provide a description of the issue*
Please describe how you are affected by the war
Other information you feel is important (optional)
Language and therapy preferences
Your English speaking ability*

NoneBasicGoodFluent
Preferred language for therapy sessions*

UkrainianEnglishPolishGermanRussian
Therapist preference*

Male therapistFemale therapistEither

Your available days and times for therapy. Please check all that apply

How did you hear about us?*

Recommendation from a family memberRecommendation from a friendSocial workerReferral from a medical or mental health professionalBrainspotting Help websiteInstagramFacebookOther
After clicking "Submit" button, please check your inbox for an email containing a link to our consent form, which outlines our support procedures and policies. Read and sign it online and our coordinator will begin to organize your support sessions.
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Health Information