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Remember Yourself application form

Name

Adress

Postcode

City

Country

Phone number

Email adress

Why do you want to participate in the program?

What do you expect from the program?

Is there a specific goal you want to achieve by completing the program?

Do you have any experience of one or more of the treatments/modalities that are offered? (please explicate which)

Which modality are you interested in to use during the program? (Please mark all possibilities that you are interested in, if you want to mix them)

Which modality are you interested in to use during the program? (Please mark all possibilities that you are interested in, if you want to mix them)

Do you have or had any of the following physical conditions?

Do you have or had any of the following physical conditions?

Do you have any physical conditions or handicap I should know about?

Do you take any medication regularly? (prescriptive or self-medication)

Do you have any psychological conditions EXCEPT anxiety, PTSD or depression?

Are you pregnant?

Are you pregnant?

Is there something else you want me to know about yourself?

Are there times and weekdays that work especially good for your schedule to book the sessions?

Are there times, weekdays or dates that do not work for you at all?

In which language would you prefer to communicate with me?

In which language would you prefer to communicate with me?

In case you are recovering from addiction, you are very welcome to the program, but you have to be at place on your journey, where you are stabil enough to handle discomfort and have found other ways to regulate your nervous system, "even" if this is just to sit with it. The program can bring up underlying fears or traumas, which is a part of the releasing process and is just temporary. Also if you are in a serious crisis in your life, it is probably advisable to wait with the program. Crisis is a psychological term, often misused in common speaking and I do not mean general upheaval or something like midlife crisis, there the program can actually be very beneficial, to get some help to sort out and look at the whys and what led to what, but if you have been NEWLY in a serious traumatic event, you will first need some specific crisis help. All participants will have the option to email me at any time during the program and I will get back to you as soon as possible, but I do not have a 24h on-call duty, which can be needed in those cases. If you recognize yourself in the above mention and are already in a recovery program or therapy lead by a professional and have come over the first steps, please consult with your professional helper if the program can be an additional help to your specific needs, otherwise are you always welcome at a later time.

I understand that non of the offered modalities is a substitute for needed professional medical or psychological treatment

I understand that non of the offered modalities is a substitute for needed professional medical or psychological treatment

I understand that Anna Gottwald is not a professional medical doctor, psychotherapist or legal adviser and that all actions I take, due to advice or suggestions during the program, are my own responsibility.

I understand that Anna Gottwald is not a professional medical doctor, psychotherapist or legal adviser and that all actions I take, due to advice or suggestions during the program, are my own responsibility.