Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Date of Birth

Last Name

Email Address

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Code

Phone

For what problem do you wish to consult? *

Mood

Relationship

Addiction

Sexual

Bereavement

Pain

Other

Please elaborate on any of the above answers.

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

I declare that the info I’ve provided is accurate & complete. I understand that any appointment booked and not cancelled within 24 hours will be charged.

Thanks for submitting!

FRANCESCA DUPRAZ-BROSSARD

COGNITIVE-BEHAVIOURAL THERAPY FOR INDIVIDUALS & COUPLES

EMDR, SCHEMA THERAPY

CLINICAL SEXOLOGY, HYPNOSIS & MINDFULNESS

(+41) 79 202 0744

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