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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