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    Notice first

    All information you provide here is strictly confidential by PSYCHUB and only serves the needs of counseling - psychotherapy. Information in (*) information is not blank.
    Please tell PSYCHUB gender:
    Please contact to make an appointment for:

    Initial information

    All information you provide here is strictly confidential by PSYCHUB and only serves the needs of counseling - psychotherapy. Information in (*) information is not blank.
    Year of Birth: (*)
    Phone number (*)
    Email (*)
    Residence

    If set an appointment for a relative

    Phone number of person receiving treatment consultation *:
    Email *:
    Year of Birth *:

    About your mental difficulties

    To complete your Consultation appointment, please take a few minutes to answer the following questions. The more detailed and clear the information you provide, the more helpful it will be for PSYCHUB to assist you with your problem or difficulty.
    1. Please describe the main problem for which you would like to receive psychological counseling: (*)
    How long has the problem been or has lasted? (*)
    2. On the scale of 1 to 5 below (with 1 being no bother or affecting anything and 5 being a major and very serious effect), rate the extent of the problem(s) you have: (*)
    3. What ways have you found to solve that problem? (You can choose more than one answer) (*)
    4. Do you have any expectations/expectations in the process of consultation - therapy (about specialists, time of therapy consultation, support policies, results....)

    Appointment information

    1. Please choose a therapy channel:
    2. Psychub contacted her to schedule an appointment through the most convenient channel: (*)
    Promo code (if any)
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