The Therapy Remedy

CBT | Clinical Hypnotherapy | Mindfulness

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Registration

Private and Confidential

Personal Details

Name(required)

Home Address(required)

Date of Birth and Age

Home Phone Number

Mobile Phone Number(required)

Email(required)

Occupation

Relationship Status

Living Situation

Do you have children?

Yes

Health Questionnaire

Have you ever been diagnosed as suffering from any psychological or psychiatric condition? If yes, please give details.

Are you currently experiencing any of the following?

Heart problems

Yes

Migraine or epilepsy

Yes

Physical pain or injury

Yes

Specific fears or phobias

Yes

If appropriate, have you consulted your GP about the condition(s) for which you are seeking therapy?

Yes

Are you currently using any prescription medication?

Yes

Do you suffer with IBS or other gastro-intestinal issues?

Yes

Do you, or have you ever, used any illegal drugs?

Yes

Do you have other health condition(s) that may be relevant? If yes, please give details.

Do you suffer with tension in any particular part of the body?

Briefly describe alcohol/caffeine intake per day/week, and number of cigarettes smoked per day if applicable.

Briefly describe your level of exercise. (Daily or weekly activities)

Briefly describe your sleep. (Trouble falling asleep? Waking during the night? Waking early?)

GP Details

GP Name(required)

GP Practice Phone Number(required)

GP Practice Email

GP Practice Address(required)

The information given above and throughout this consultation is, to the best of my knowledge, full and correct. (required)

The Therapy Remedy Ltd
Black Sheep Croft
Isle of Lewis
HS2 0SJ

(01851) 850700
07974693070

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Home
How I Can Help
About
- About Me
- FAQs