Therapy sessions for unresolved issues

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 unresolved issues?
less than a year 1-2 years 2-5 years 5-10 years Over 10 years

Is there any particular time when you feel that unresolved issues effect you most?
Yes No

If yes to above please give details


Is there any particular situation that you feel that unresolved issues affect you most
Yes No

If yes to above please give details


How often would you say you suffer from the effects of unresolved issues?
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 unresolved issues. Including anything you may think is relevant no matter how silly it may sound