Appointment Form

Appointment Form

Thank you for choosing AnxietEase! Please fill out the following information to book your personalized therapy session.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemaleOther
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?*
Panic attacksConstant worryDifficulty sleepingDifficulty concentratingMuscle tensionIrritabilityRapid heart rateShortness of breathOther
NoIf yes, please specify
NoIf yes, please specify
YesNoIf yes, please specify
Hashil's Appointment*
Choose your Package*
prevnext( X )
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

Total

£0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.