Therapy sessions for the fear of the dentist

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

How long have you been suffering severe fear of dentists?
less than a year 1-2 years 2-5 years 5-10 years Over 10 years

Is there any particular time when you feel the fear started?
Yes No

If yes to above please give details

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 fear of the dentist. Including anything you may think is relevant no matter how silly it may sound