REGISTRATION FORM

All data that you write down or communicate in confidence remains with the AMT trainer in this case Fatima Boutaka and is not shared with third parties (if there is an urgent reason to consult with other professionals, this will always be first consulted with you and/or your parents).

Surname and first name:

Address and city:

Phone:

E-mail address:

School / Type:

Class:

What is your reason for registering?

2. Are there things you think are important to tell before the training?

You can think of something that makes you feel vulnerable, that you suffer emotionally or physical complaints.

It is important to me that:

I sometimes feel vulnerable about:

Physically I suffer from:

3. What things do you like to do? And how often do you do this?

4. What things do you find difficult in your life right now?

How often do you deal with this?

5. Have you ever been (or are you still) treated by a psychologist or other care provider?

Can you indicate what this was or is for?

6. Have you ever taken any medication (yes/no)? Or are you currently on medication? (Yes No)

7. If yes: what are these?

8. What would you like to learn in the training?

9. I sign up for:

start on

Thank you! we have received your data.