Appointment Form
Thank you for choosing AnxietEase! Please fill out the following information to book your personalized therapy session.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Gender
*
Male
Female
Other
When did you first start experiencing anxiety symptoms?
How frequently do you experience anxiety (e.g., daily, weekly, etc.)?
On a scale of 1-10, how severe do you rate your anxiety currently?
*
Do you experience any of the following symptoms? (Check all that apply)
*
Panic attacks
Constant worry
Difficulty sleeping
Difficulty concentrating
Muscle tension
Irritability
Rapid heart rate
Shortness of breath
Other
Have you been diagnosed with any mental health conditions? (Yes/No)
*
No
If yes, please specify
Are you currently undergoing any treatment for anxiety or mental health conditions?
*
No
If yes, please specify
Are you taking any medications for anxiety or other mental health issues?
*
Yes
No
If yes, please specify
Hashil's Appointment
*
Choose your Package
*
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Discounted Offer Monthly Package (4 x 60-minute sessions)
Monthly 4 sessions with Hashil (4 x 60-minute sessions)
£
120.00
1:1 Therapy Session
Individual Online Therapy Session (60 minutes) with Hashil
£
35.00
No. of Sessions
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
Please click one of the PayPal options to complete payment and
submit
the form.
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