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 that you have suffered from low self-esteem Select time that you have suffered from low self-esteemless than a year1 to 2 years2 to 5 years5 to 10 yearsover 10 years

Please tell me about your first memory of low self-esteem

Is there any particular time when you feel that your self-esteem is at its lowest? 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 low self-esteem and how they make you feel. Including anything you may think is relevant no matter how silly it may sound.Message