Questionnaire1

These information will help us understand you better and facilitate your therapy.

Name *

First

Last

Address *

Line 1 *

Line 2 *

City *

Post Code *

Appointment Date *

Marital Status *

Date of Birth *

Phone Number *

Appointment Type *

Age *

Email *

Occupation *

Your Subjective Unite of Distress. Please rate the stress level of your problem using a number between 0-10 with 10 being the highest and 0 being none at all. *

Please take some time to think before you answer the two questions below. If necessary come back to it.

Please write a synopsis of your problem and list what you would like to change/improve *

How would you know when you have achieved your goal? *

Are you currently taking any medication *

Yes No

If Yes please specify: *

Have you ever had psychiatric treatment? *

Yes No

Have you recently gained or lost weight? *

Yes No

Have you any physical/medical condition? *

Yes No

If Yes please specify: *

Have you recently consulted your doctor? *

Yes No

If Yes please specify: *

Doctor's name? *

Optional

If Other please specify: *

After we have helped you resolve your problem for good would you be happy to discuss your experience with our public relations team? *

Yes No Maybe

If Other please specify: *

Consultation Questionnaire - Strictly Confidential

Please take some time to think before you answer the two questions below. If necessary come back to it.

Optional