Registration - Forms - Dr. Daniel Zeiss

Mentoring registration

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Personal Information

Saludation(Required)

Mrs

Name(Required)

Firstname Lastname

Date of birth(Required)

MM slash DD slash YYYY

Place of birth(Required)

Address(Required)

Street Street 2 City ZIP / Postal Code Country

Email(Required)

newsletter

I would like to sign up and receive irregular email updates (newsletter) from Daniel Zeiss. See privacy policy.

Phone / Cell phone(Required)

Phone / Cell phone 2

Buddy Information

A buddy is a person close to you. This can be a partner, family member, neighbor who is close to you in the same area. This buddy is needed for your security when doing online sessions. The buddy will not get to know anything that is talked about in the session. He / She is just a security measure.

Buddy name(Required)

Firstname Lastname

Buddy email(Required)

Buddy phone / cell phone(Required)

1. What brings you to coaching? What do you hope to achieve?

2. How long have the complaints existed?

3. What have you tried so far to resolve the issue? Which methods/ tools have you used?

4. Do you use other methods of personal development or coaching? Which?

5. Do family members or relatives have similar issues as stated above?

6. Are there illnesses in your direct relationship like cancer, multiple sclerosis, schizophrenia, suicide thoughts, hearing voices? If so, please explain.

7. Are you in psychiatric, psychological or psychosomatic treatment? Why?

8. Have you ever seriously considered committing suicide?

9. Have you ever made a suicide plan?

10. Have you ever attempted suicide?

11. Do you suffer from diseases such as diabetes mellitus, herniated discs or heart disease? Are you taking medication (for the above or other diseases)?

12. Are you taking or taking addictive or mind-altering substances? (Nicotine, medication, drugs)? Please also state how long you have been taking it.

13. Have you experienced major life-changing events? If yes, which?

14. Is there anything else we should know?

Current portrait photo

Max. file size: 256 MB.

Please upload a recent portrait photo here. This helps us to make sure that the person who has registered is the person who will participate in the coaching. On the portrait photo, the face should be well recognizable, i.e. no sunglasses, face-covering or similar.

Consent(Required)

I agree to the data processing.(Required)

I hereby confirm that I have read and agree to the Privacy Policy.

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Clarity to do what is right - Mentoring

Mentoring registration

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