Therapy sessions for low self esteem

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

Times you are available for an appointment?

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

How long have you been suffering from low self esteem?
less than a year 1-2 years 2-5 years 5-10 years Over 10 years

Is there any particular time when you feel your self esteem is at it's worse?
Yes No

If yes to above please give details


Is there any particular situation that your self esteem drops?
Yes No

If yes to above please give details


How often would you say you feel really bad about your self?
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 low self esteem. Including anything you may think is relevant no matter how silly it may sound