Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Availability *

Please Tick your availability for sessions

Please tick if you can attend appointments any day (Tuesday to Thursday - 10am to 7pm)

Tuesday Morning (10am to 12pm)

Tuesday Afternoon (1pm to 4pm)

Tuesday Evening (5pm to 7pm)

Wednesday Morning (10am to 12pm)

Wednesday Afternoon (1pm to 4pm)

Wednesday Evening (5pm to 7pm)

Thursday Morning (10am to 12pm)

Thursday Afternoon (1pm to 4pm)

Thursday Evening (5pm to 7pm)

Questions to consider before booking your initial assessment. Please tick each box to confirm. *

I am aware that sessions are collaborative and work will need to be completed in between sessions

I can attend the first four sessions on a weekly basis

I am aware that sessions are via Zoom

Have you been diagnosed or experienced any symptoms regarding the following disorders?

Bi-Polar Disorder, Schizophrenia, Personality Disorders, ADHD, or Autism Spectrim Disorder

Reasons for seeking therapy at this time (tick as appropriate) *

I feel anxious around others

I find it difficult to control worry

I struggle with my self esteem and self worth

I am finding my mood low

I am anxious around my health

I have experienced trauma (childhood sexual abuse/domestic abuse/natural disaster/serious car accident)

I am experiencing panic attacks

I am feeling little joy in my life

I find myself feeling stressed and overwhelmed

I struggle with people-pleasing and saying no/ setting boundaries

Are you seeking a programme or individual sessions? *

I am interested in individual Sessions

I am interested in The Barrister Programme

I am interested in The Business Programme