I would like to book a:
Skype Private Session
Your full name
Your date of birth:
Address line 1
Address line 2
Your telephone number
Your relationship status (Married/single/divorced/in a relationship/etc)
Who else lives with you:
What are your expectations of the session and how the session will be structured:
Brief outline of the problem:
What makes it worse:
If you didn't have this problem, how would your life be different?
Is there anything about your situation that would be helpful for me to know?
If the problem is weight/eating related, what is your weight and height:
Please list any current physical health problems:
Please list previous significant medical or surgical problems:
Please list all medication currently taken:
Have you ever suffered a head injury that resulted in loss of consciousness or brain trauma?
Have you received in-patient psychiatric treatment, and if so: what, where and for how long?
Approximate alcohol intake per week:
Do you smoke? If so, how much?:
Any other drug use?
Hobbies and interests:
What stops you from changing?
What will be different once you have changed?
How will this change affect family and friends?
What has been your best accomplishment to date?