• New Client Questionnaire

  • do the exercises on the accompanying PDF guide before filling this form. If you don't have it, click HERE to download it. 

     

    * At the end you'll be able to save a PDF of this form with all your answers.  

    * Do not refresh this page otherwise you'll lose all your answers.

    * Be sure to read every question very carefully. 

  • YOUR DETAILS :

  • Please fill in your name (surname is optional) and your best email address :*

  • 1) GETTING AROUND & DISTANCES :

  • - Walking

    - Electric scooter

    - Cycling

    - Motorbike/Scooter/Moped

    - Driving

    - Bus

    - Coach

    - Train

    - Tram

  • 2) TYPES OF ENVIRONMENT :

  • - Graveyard

    - police station

    - crowded places

    - loud/busy places

    - Bus station

    - Large, busy train station

    - Tall buildings, grand environments (i.e. large square, park, monuments)

    - open spaces

    - enclosed spaces

    - shopping mall

    - water (canal, river, lake, sea)

    - supermarket

    - Bank

    - Post office

    - main roads

    - side streets / back streets / alleyways

    - unfamiliar / unusual / different environment- weird / bad vibe, feel out of place, don’t like a place, don’t feel comfortable

  • 3) TYPES OF JOURNEY/TASK :

  •  - Visiting a friend

    - Going shopping

    - cinema / theater

    - bar / restaurant

  • 4) FACTORS THAT MIGHT

    MAKE YOU ANXIOUS :

  • Things that make you more prone to, contribute to, trigger or exacerbate anxiety/agoraphobia, at any time, whether before or during a journey or task.

     

    - Eating too soon before leaving

    - Eating while out

    - Being out of breath

    - Being thirsty (dry mouth/feeling dehydrated)

    - Being hungry

    - Being sleepy / tired

    - Rapid heartbeat

     

    - Not taking certain items with you :

     


    * Mints / sweets / chewing gum

    * Menthol inhaler or something that you feel helps you breathe more easily

    * A tablet of some kind

    * Water bottle

    * An object to feel comfortable or reassured

    * Map/directions/instructions/information

    * Item to keep you distracted/occupied (i.e. book/newspaper/phone)

     

    - Walking fast

    - Walking slow

     

    - Sticking around in a place

    - Unplanned / spontaneous detour

    - Being lost / disoriented

     

    - Thinking about personal problems

    - General negativity

    - Morbid / inappropriate thoughts

    - OCD related stuff

    - phobias, triggers, associations

     

    - Interacting with people (i.e. asking for directions)

    - Getting involved with your environment/surroundings (i.e. going into a shop)

  • WHERE YOU LIVE :

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  • WHAT HAPPENS NEXT :

  • * Do not refresh this page otherwise you'll lose all your answers. 

    * Please read all of these steps first and then follow them carefully.

     

    1) Click on Review Answers (below). 

    2) After reviewing your answers, click on Review Answers again and scroll down to the bottom of the page.

    Once all the required questions are answered you'll see Print and Submit (Don't submit yet!)

    3) Do this before submitting this form : Save your answers by clicking on Print, then next to Destination use the drop down menu and select Save As PDF. 

    4) Click on Submit (you can now close this tab). 

     

     

     

    * as soon as I receive this completed form I'll get to work putting together the guidelines for your first mission

    * once I've done that I'll get in touch. please check your email often

     

    * when you do each mission, fill in the mission report form, the link will be at the end of the mission guidelines PDF

     

    Thank you, and I look forward to chatting with you soon. 

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