Initial Assessment Form

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Full name *

Date of birth *

Email *

Phone Number / Telegram / WhatsApp *

Country and City/Area of Residence *

Occupation
*

Relationship status (single, married, civil partnership, cohabiting) *

Medical condition/s
*

Medications (including herbal remedies, and recreational drugs)
*

Allergies
*

Diagnosed psychological problems?
*

How did you first find out about me?
*

Select from the list of issues, if any, affecting
*

Anxiety

Stress

Motivation

Addiction, drugs

Fear/Phobia

Panic attacks

Alcohol

Pain

Sleep

Obsessions/Compulsions

Confidence, Self-esteem

Insecurity

Grief, Loss, Separation

Anger

Depression

Marriage/Relationships

Sex/Intimacy

Trauma, Abuse or PTSD

Suicide

Self harm

None of the above

Required

Which option do you prefer?
For more details about the available packages, please click here *

Individual Session

Package: Managing Anxiety and Overcoming

Package: Overcoming Irrational Fears and Phobias

Package: Working With Obsessive Thoughts and Compulsive Behaviour

Package: Improving Relationships with Others

Package: Improving Self-Esteem and Self-Confidence

Package: Processing Emotional Traumas

Package: Overcoming Limiting Beliefs

Package: Stress Reduction and Improved Sleep

Package: Resolving Intrapersonal and Interpersonal Conflicts

Package: Personal Transformation and Unlocking Potential

Package: Working with Psychosomatic Disorders

QHHT Session

Other

Required

How to benefit most from sessions

· Personal change can be swift or slow dependent on many factors, including personal motivation, the severity and complexity of the problem, how ambitious your goals are, etc. Please be patient!

· Come with a positive expectation that the session will be helpful and productive.

· Speak openly about your ideas of what will help.

· Understand that change often requires practice and perseverance.

· I am normally contactable by telephone 9am to 5pm each day or you may leave an answerphone message. I will endeavour to return your call within 24 hours.

· I will not make decisions for you, but I will offer suggestions if this is desired.

· Please provide 48 hours’ notice by telephone if you cannot attend your appointment.

Thank you again for coming to see me. I look forward to working with you towards positive outcomes.

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