Personalised hypnotherapy form for Anxiety.

Name

Email Address

Select your age Select your age18-3031-4546-6061-750ver 75

Your Phone number (Optional)

select your gender select your genderMaleFemaleOther

Select time you have suffered from anxiety Select time you have suffered from anxietyless than a year1 to 2 years2 to 5 years5 to 10 yearsover 10 years

Please tell me about your first memory of anxiety

Is there any particular time when you feel most anxious? If yes please tell me about it.

Do you suffer from any allergies? If yes please give details.

Do you take any mind altering medication? If yes please give details

Please tell me in your own words and as much detail as possible about your Anxiety and how it makes you feel. Including anything you may think is relevant no matter how silly it may sound.Message