Therapy sessions for lack of confidence

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

How long have you been suffering from a lack of confidence?
less than a year 1-2 years 2-5 years 5-10 years Over 10 years

Is there any particular time when you feel less confident?
Yes No

If yes to above please give details


is there any particular situation that makes uneasy?
Yes No

If yes to above please give details


How often would you say you find yourself in a situation where you feel really uncomfortable and lack confidence?
Occassionally Frequently All the time

Do you suffer from any allergies
Yes No

Are you taking any mind altering medication?
Yes No

Please tell me in your own words and as much detail as possible about your lack of confidence. Including anything you may think is relevant no matter how silly it may sound