Therapy sessions for Phobia

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

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

Is there any particular time when your phobia is at it's worse?
Yes No

If yes to above please give details


Is there any particular situation that makes your phobia bad?
Yes No

If yes to above please give details


How often would you say you suffer from your phobia?
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 phobia. Including anything you may think is relevant no matter how silly it may sound