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FreeYourMind.UK Intake Form

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Designed For You.

Intake Form

We're looking forward to helping you.

Before our appointment, it will be appreciated if you can complete the following:

1) Your name 2) Your email address 3) Your phone number 4) What is the concern? What do you want to move away from? 5) How will the new you be? What do you want to move towards? This is the most important question! Please take as long as you need on the answer. 6) How will the new you feel different? 7) Have you had therapy before? What for; how long ago; how was it? 8) Are you undergoing any medical treatment? E.g. epilepsy, asthma, psychosis, pace maker, mental wellbeing 9) Are you using any medication or drugs? 10) Have you had recent serious thoughts about hurting yourself or others? 11) Are you ready to make this change?

Coaching and online therapy for anxiety, anger, trauma, fear, smoking, weight loss in London and Guildford.