Anxiety House SC New Client Initial Appointment Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Date of Birth* This field is required.
Date
Day
Month
Year
4
Contact Number* This field is required.
Enter your mobile or best contact phone number
5
What are your main concerns?* This field is required.
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Small
Ok
Ok
6
Have you seen a psychologist or psychiatrist before?* This field is required.
YESNO
7
Are you currently taking any medication?* This field is required.
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Large
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Small
Ok
Ok
8
What are your best days and times for appointments?* This field is required.
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Small
Ok
Ok
9
What personality traits would you like in a therapist?* This field is required.
Please Select
Please Select
Outgoing
Reserved
Action Focused
Reflective
I don't mind
10
What type of therapy do you prefer?* This field is required.
Please Select
Please Select
Supportive therapy
More directive skill building therapy
Combination of supportive and skill building
Virtual Reality Therapy
Unsure
11
Who among the team would you prefer to see?* This field is required.
Please Select
Please Select
Whoever you suggest
Amber Rattray
Jessica Sloane
Josephine Miller
Shannon Tyrie
Lucille Griffiths
Brad Shaw
Jenny Booth
Kathryn Esparza
Vera Keatley
Renee Curan
Crystal Smith
12
How did you hear about us?* This field is required.
Should be Empty: