Allianz Patient Form

To enable your psychologist to prepare for your first session and to ensure that you get the most benefit from this, please complete the following questionnaire which will provide them with a brief outline of the problem(s) that you would like to address.

Name *

Address *

Address

Address

Address

City

City

County/State/Province

County/State/Province

Post/Zip Code

Post/Zip Code

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Country

Phone *

Authorisation Code *

Allianz Membership No. *

Number of sessions authorised

Email Address *

1. How would you describe your problem/what are your main symptoms (including psychological/emotional and physical, as appropriate)? *

2. How long have you had this problem? *

3. What makes it better? *

4. What makes it worse? *

5. Have you made any attempts to solve this problem before now? *

Appointment Structure and Cancellation Policy

Sessions are 50 minutes and take place weekly at the same time. The appointment continues each week until you decide to conclude therapy (written or verbal notice required).

We ask for at least 24 hours’ notice for any changes.

Two notified cancellations are permitted within each block of 20 paid sessions without charge. A notified cancellation requires at least 24 hours’ notice. Cancellations with less than 24 hours’ notice, or additional cancellations beyond this allowance, are charged at the full session fee.

Please confirm that you have read the policy above *

I confirm that I have read and understood the appointment structure and cancellation policy.

Age *

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