Book An Appointment

Book An Appointment

Thank you for getting in touch and your interest in exploring how I may be able to help you. Below are some questions to let me know a bit about what you would like help with. This will start to help me understand how I can best support you and maximise our time on the day. I look forward to meeting you. Thanks, Jay
Name*

First NameLast Name
Email*
example@example.com
Contact Number*
What would you like help with right now?*
How do you feel this is impacting upon your quality of life?*
What would it mean to you if this could be changed? How would it help you to feel?*
On a scale of 1-10 how motivated are you to achieve this outcome right now (1= not at all, 10= I'll do whatever it takes)?
In order to be able to undertake some treatment on the day please complete the following questions.
Have you any been diagnosed with any medical conditions not mentioned above?
Have you experienced or been diagnosed with any of the following:

Brain TumourAcute Stroke or TIACereberal AnuerysmHemorrhageHerniated medulla oblongataRecent skull fractureCerebrospinal fluid leakSpina BifidaArnold Chiari Malformation
Are you or could you be pregnant?

YesNo
Please tick any of the following time periods you would generally be available to attend an appointment within.*

Tuesday Morning (10am-2pm)Tuesday Afternoon (2-6:00pm)Friday Morning (10am-2pm)Friday Afternoon (2-6:00pm)
Let me know if there is anything to know about your availability within the times you've selected.
Upon receipt of this form I'll contact you with the next available appointment in the time slots offered.
What is the best way for me to get in touch to receive your appointment information and for us to communicate.

WhatsappText Message/ SMSEmailPhone call
If you have not had a response from me within within 48 hours (not including weekends) contact me directly on 07552 62 72 82 or hello@intobalancetherapies.co.uk.

I look forward to seeing you and finding out how I can help.

Cheerio

Jay
Appointment
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