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Anxiety Questionnaire

Please fill out the following form in order to participate in our activity.


Health Assessment


Please tick all that apply

Are you currently experiencing any of the following?

Please tick all relevant fields.
Please tick all relevant fields.
Do you use ‘recreational’ drugs?
Have you ever been diagnosed as suffering from any other psychological or psychiatric condition?

(Includes but not limited to bipolar disorder, schizophrenia, multiple personality disorder, psychotic episodes, Borderline personality disorder).

Do you have any other health conditions which you feel might be relevant?
Have you consulted your GP (if appropriate) about the condition for which you are seeking help?
Where did you hear about me?

Terms & Conditions

This contract details the terms and conditions concerning our work together. 


  • The agreement to work on the issues presented by the client in no way guarantees a cure. 

  • Cancellation with less than 24 hours’ notice will cause the client to be liable for the full cost of the session. 

  • Listening to audio meditations will not be done whilst driving or operating machinery.

  • Contact between sessions will be limited to email:

  • Your welfare is my primary concern and will only take second place if not to do so would seriously jeopardise other members of the public or my welfare.

  • Confidentiality will be maintained in all but the most exceptional circumstances. These can only include: legal action (criminal or civil court cases where a court order is made demanding disclosure - includes coroners courts) and where there is good cause to believe that not to disclose would cause danger of serious harm to self or others. Most standards of confidentiality applied in professional contexts are based on the Common Law concept of confidentiality where the duty to keep confidence is measured against the concept of "greater” good. The sharing of anonymous case histories with supervisors and peer-support groups is not a breach of professional confidentiality. The sharing of open case histories with supervisors and any referring NHS medical practitioner is also not a breach.

  • You agree to take 100% responsibility for your own health & wellbeing.

  • You agree to put in writing any concerns or challenges that need addressing prior to the next session

  • You are agreeing to the full terms & conditions & disclaimer stated here & extended version on our website.

  • I understand that any identifying personal details will NOT leave my case notes.

  • Notes of the sessions will be kept and are available to the client with reasonable notice. 

By pressing the submit button you agree to the terms above.

Thanks for submitting!

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