Therapy sessions for unwanted habits

First Name:

Last Name:

Email:

Age:

Sex:
Male Female

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

Is there any particular time when your habit is at its strongest?
Yes No

If yes to above please give details


Is there any particular situation that makes your habit worse?
Yes No

If yes to above please give details


Do you know of any gains you might get from your habit?


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 unwanted habits. Including anything you may think is relevant no matter how silly it may sound