Psychology Consultation Request Form

Hello, and thank you for your interest.

My name is Lorelei Van Hees, and I am a clinical psychologist. I work with adults and adolescents who are experiencing emotional difficulties, life transitions, stress, anxiety, depression, relationship issues, or other concerns that may be affecting their well-being.

The sessions are held online in a confidential, safe, and respectful environment where you can speak openly about your concerns, goals, and needs.

The purpose of this form is to collect some initial information that will help me better understand the reason for your request and prepare for our first session.

Once you have submitted the form, I will contact you by email to confirm your appointment and provide all the necessary information for our first meeting.

Thank you for your trust.

Lorelei Van Hees

Clinical Psychologist

INFORMED CONSENT FOR ONLINE PSYCHOLOGICAL SUPPORT

This document is intended to provide you with information about online psychological support. By checking the consent box and submitting this form, you confirm that you have read, understood, and freely agreed to the terms outlined below.

Online sessions

Sessions are conducted remotely via a secure video conferencing platform. Online consultations may be subject to technical limitations beyond the psychologist's control, including issues related to internet connection quality or unexpected service interruptions. If technical difficulties occur, an alternative solution may be offered, such as a telephone session or rescheduling the appointment.

You are responsible for ensuring that you are in a quiet, private setting that allows the session to remain confidential throughout its duration.

Confidentiality and data protection

The psychologist is bound by professional confidentiality in accordance with the applicable Code of Ethics. No session will be recorded, stored, or shared with third parties without your prior written consent.

Personal data collected as part of the psychological support process are processed in accordance with the General Data Protection Regulation (GDPR). Your data are stored securely and confidentially, and you have the right to access, correct, or request the deletion of your personal data in accordance with applicable legislation.

Emergencies and limitations of the service

Online psychological support is not an emergency service. If you are experiencing an acute mental health crisis or are at immediate risk of harming yourself or others, you should contact your local emergency services immediately (112 in many European countries, or your local emergency number).

Where clinically appropriate, you may be referred to a healthcare provider or specialist service better suited to your needs.

Fees and cancellation policy

Each session lasts approximately 60 minutes.

The fee for each consultation is €40. Payment must be made using the agreed method, such as bank transfer or an online payment platform.

Appointments cancelled less than 24 hours in advance will be charged in full, except in exceptional and duly justified circumstances.

You may end the therapeutic process at any time. Whenever possible, a final session is recommended to provide an appropriate conclusion to the therapeutic work.

Consent

By submitting this form, you confirm that you are at least 18 years old or are the legal representative of a minor, that you have read and understood the information provided above, and that you freely consent to receiving psychological support online.