Consultation Form

1
Name
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email
example@example.com
4
Phone Number
Area Code
Phone Number
5
Any Allergies?
YESNO
6
Any Injuries or Recent Surgeries?
YESNO
7
What type of physical activity are you doing or have done?
8
How does your body feel at the moment?
9
Any mental health issues now or in the past?
10
What do you do for work?
11
What are your work hours like?
12
Who are you responsible for taking care of outside of work?
13
How do you sleep?
14
How is your eating pattern and diet?
15
What are your stress levels like? What causes your stress? How do you manage it currently? Short or long term?
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Small
Ok
Ok
16
How would you describe yourself?Please be as open, honest and descriptive as possible.
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Ok
17
Have you ever tried Yoga, Meditation or Wholistic and Energy Therapies in the past? Please give details of what they were and your experience.
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Ok
Ok
18
The next questions are for Integral Eye Movement Therapy that may have been discussed with you. The questions are for anything that may be contraindicated.
19
Emergency Contact details (Name, Telephone Number and Relationship)
20
GP Contact Details
21
Current state of healthBrief description of anything that may be affecting you currently
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Ok
Ok
22
Are you on any medication, if so what:
23
Do you have any neurological, ocular or medical issues?
24
Do you have a history of psychosis or psychotic conditions?
25
Do you suffer from epilepsy?
26
What would you like to change about your current situation?
27
Out of 10 how much do you want this change?0 being the least and 10 being the most
28
Why haven't you been able to make this change so far?
29
Have you seen or currently seeing any other therapist for this issue?
30
Do you experience any negative emotions for example guilt and anger?
31
Is there anything specific that makes these issues worsen?
32
Are there any particular negative memories associated with these issues?
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Ok
33
What would your life be like without these issues?
34
Any other information you think I should know about in regards to these issues?
35
What would you most like to achieve from the session?Short and long term
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Ok
Ok
36
What would you like to release physically, mentally and emotionally?
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Ok
37
Is there anything you would prefer not to discuss during the session?
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Ok
Ok
38
I understand the therapy session involves techniques to promote stress reduction. I understand the sessions may have varying results and that my experience is my own. I understand these sessions are not a substitute for qualified medical or psychological care.
YESNO
Should be Empty: