Falling Upwards - Psychology-Driven Solutions

Are you happy to adhere to the data protection policy?

Full Name

Date of Birth

1st Line of Address

Town/City

Postcode

Email Address

Contact Number

Can you please say how things are for you at the moment?

What prompted you to come for therapy?

Have you previously had therapy?

Are you currently working with any service or agency (e.g. NHS, Police, Alternative Health Practitioner)?

Are you currently taking any prescribed medication?

Are you currently taking any non-prescribed medication?

Your privacy is important to us. All information shared is confidential and protected under our Privacy Policy.

Psychological Therapy / EMDR