Neurofeedback Therapy – Free 30-Minute Consultation Form

Please complete this short form ahead of your free 30-minute consultation. This helps me understand what you're experiencing and whether neurofeedback therapy may be a good fit for you.

Personal Details

Full name

Date of birth

Email address

Contact number

Town / City (optional)

Name and address of GP (optional)

About You & Your Nervous System

What has prompted you to explore neurofeedback therapy at this time?

How would you describe how your mind and body feel on a typical day?

Are there particular patterns you notice that you'd like to understand or change?

Areas You're Interested in Exploring (tick any that apply)

Previous Experience

Have you previously tried talking therapy, EMDR, coaching, medication, mindfulness, or neurofeedback?
If yes, what was helpful or unhelpful?

Health & Safety

Are you currently working with other professionals?

Are you taking prescribed medication?

Yes

Any history of seizures or neurological conditions?

Yes

What You're Hoping For

What would you hope to gain from neurofeedback therapy?

Is there anything else you'd like me to know?

Neurofeedback Therapy

Neurofeedback Therapy – Free 30-Minute Consultation Form

Data Protection

Personal Details

About You & Your Nervous System

Areas You're Interested in Exploring (tick any that apply)

Previous Experience

Health & Safety

What You're Hoping For

Neurofeedback Therapy

Neurofeedback Therapy – Free 30-Minute Consultation Form

Data Protection

Personal Details

About You & Your Nervous System

Areas You're Interested in Exploring (tick any that apply)

Previous Experience

Health & Safety

What You're Hoping For