Coaching Sessions

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Please tell me your name.* Dies ist ein Pflichtfeld.
First Name
Surname
2
Please, tell me your email address.* Dies ist ein Pflichtfeld.
Your best email
Confirm Email / Bestätige deine Email
3
Please, tell me your telephone number, at best connected to whatsapp/telegram.* Dies ist ein Pflichtfeld.This serves as a backup conversation channel, as well as to inform you further after our session.
Country code
Prefix number
Phone number
4
What made you reach out to me?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
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Large
Normal
Small
Ok
Ok
5
Have you done psychotherapy or coaching before?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
6
Did you attend one-on-one or group session or both?
One-on-one
Group
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Which of the below did you experience in the last two weeks?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
none
depressive moods
anxiety
grief
conflict
social isolation and/or feelings of loneliness
(major) life change
psychosomatic symptoms (symptoms like pain without physical cause)
Other
8
Please fill out the PHQ-9 for the screening of your depression!
9
Please tell me your PHQ-9 test scoreThis information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
10
Do you have a diagnosed mental disorder according to ICD-11 or DSM-V, including ADHD and/or autism?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
11
Please fill in the diagnostic code or description, if you know it.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
12
Are you taking regulary specific medication for mental health issues?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
13
Please share with me your medication.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
14
Did you experience some form of trauma or abuse in the past?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
15
Which trauma or abuse did you experience?This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
16
Do you display addictive behaviour regarding substances, sex, work etc.?* Dies ist ein Pflichtfeld. This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
17
In the past month, have you had thoughts to end your life?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
18
What Kind of Thoughts?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
Active thoughtsPassive thoughts
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Please describe your thoughts or plans.* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
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Large
Normal
Small
Ok
Ok
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Do you plan to end your life in the next two weeks?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
Yes
No
Unsure
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Did you try before to end your life?* Dies ist ein Pflichtfeld.This information will be treated confidential. It will help me to decide if I can offer you support or if further support is needed..
YesNo
22
If you want to connect before the call, write directly to me on Whatsapp!
23
In which country is your tax residenceTo apply the correct amount of VAT I need this information.
Please Select one!
Please Select one!
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Billing address* Dies ist ein Pflichtfeld.For your invoice and the correct amount of VAT, I need this information.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Book your first coaching session (50 min.)!* Dies ist ein Pflichtfeld.
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Any further notes or message to me?
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Large
Normal
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Ok
Ok
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Terms and conditions for participation* Dies ist ein Pflichtfeld.The following consents are necessary to comply with GDPR. All data is stored securely on servers in Germany and cannot be viewed by third parties, nor will your data be passed on to third parties. Your data can be deleted at any time on request. Privacy policy | Terms and conditions
I agree to the privacy policy, terms and conditions and the temporary storage of my data for the purpose of conducting the initial consulting session!
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