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ALMA VIVA PSY

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First Appointment

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First Name

Last Name

WhatsApp

Email

Consultation Type *

In-person

Online

Preferred Date *

Preferred Time *

Modality *

Individual

Couple

Parental Guidance

Groups

Updates since the last session

1. Personal Data

First Name *

Last Name *

Date of Birth *

WhatsApp (with country code) *

Email *

Country of Residence *

Address / City *

Profession

2. About the Consultation

Consultation Type *

Online

In-person

Preferred Date

Preferred Time *

Session Modality *

Individual

Couple

Parental Guidance

Groups

3. If Underage

Are you underage? *

No

Yes

Guardian’s name *

Guardian’s WhatsApp *

4. Clinical History

Have you previously received psychological/psychiatric care? *

Yes

No

Are you currently taking any medication? *

Yes

No

Preferred language *

How did you hear about Alma Viva Psy *

5. Reason for Consultation

Reason for Consultation *

6. Final Declarations

I declare that the information provided is true. *

I authorize Alma Viva Psy to process my personal data in accordance with the GDPR. *

Psychology with listening, respect, and welcome in your language.

Contacts

Luxembourg
Address available upon confirmation

contato@psicologadircelena.com

+352 661 071700

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