Werner Pitzal

Questionnaire to prepare for your psychotherapy / coaching

I am looking forward to a successful cooperation with you.

In order to be able to use the time in the first session fully for your concerns, I ask you to fill out this questionnaire and send it to me at least 3 days before our appointment. Thank you!

With best regards,
Werner Pitzal

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All fields marked with * are mandatory.

You will find the terms and conditions (GTC) here, and the initial information in the email with the confirmation of our first appointment.

Cost subsidy for psychotherapy: If you want to apply for a grant from your health insurance company, please inform yourself about the conditions here and also answer the last 3 questions.

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Name *

Address *

Date and Place of Birth *

Phone *

Email *

Profession *

Referral *

Partner

Duration of relationship

Married?

Children

Support so far *

Initiating event *

Difficulty *

Strengths and resources *

Intention

Result *

Health insurance grant

If you would like to apply for a cost allowance from your health insurance company, I would ask you to inform yourself about the conditions at www.pitzal.at/faq/kk and to answer the following 3 questions.

Health insurance company

Social security number

Additional insurance

GTC *

I have completely read the terms and conditions (GTC) at https://www.pitzal.at/agb/?lang=en and the initial information in the email, and accept them.

GDPR, in Austria DSGVO *

In accordance with the General Data Protection Regulation (GDPR, in Austria DSGVO), I expressly agree that my personal data (i.e. email or sms communication, the data contained in this form, and the handwritten minutes of psychotherapy or coaching sessions) may be processed by Werner Pitzal for the purpose of providing the 'Psychotherapy' or 'Coaching' service. The data is subject to strict psychotherapeutic confidentiality and will never be passed on or made available to third parties. This consent can be revoked at any time via email to office@pitzal.at.

Security Test *

Please type the number-letter combination in the field below the words ’Security Test'. By clicking on the arrow circle you can request another combination if necessary.

Please send me your questionnaire by clicking on 'Send' - thank you!

Thanks a lot! All your data is of course subject to strict psychotherapeutic confidentiality, is transmitted in encrypted form (SSL protocol), and is only viewed by me personally.

If you cannot send the questionnaire because of the error message "CSRF Token Verification Failed", this is because the browser window was open for a very long time (more than 3 hours), and therefore for security reasons the SSL connection necessary for the transmission of confidential data was interrupted.

Solution: In a second browser window, or even better in another browser, open the questionnaire a second time via the link https://www.pitzal.at/questionnaire/1/, copy the contents and send it immediately.

Psychotherapie • Paartherapie • Coaching

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