eMail Counselling+ Booking Form

Required fields are marked with a green background.
Are you currently experiencing specific suicidal feelings or are you in a dangerous crisis where you, or someone close to you is at risk of injury?
Counsellor
Full-name Title
Full Postal Address
Phone number eMail only please
eMail Address
Please re-enter eMail Address
Session Type
Issue
When did the issue start?
How were you before the issue started?
Background for the issue
GP name and address?
When did you last visit your GP? When?
For what condition?
What medication are you currently on? Prescription
Non-prescription
Any periods of hospitilisation in the last 5 years? Physical issues
Psychological issues
Ever diagnosed with a heart condition?
Ever diagnosed with or treated for a psychiatric condition inclusive of any form of depression?
Current and past alcohol intake and recreational drug use
In the last 3 years have you been treated by a psycological therapist / psychiatrist?
When is your goal? What do you want to achieve?
Please complete this additional form and transfer the resulting values (click here - opens in a new window)
How did you hear about Changing States
Hold the shift key down to make multiple selections.
If other:

Notes

Click here for fee schedule(s). After completing this form you will be driected to the Changing States shop to pay for your eMail based Counselling+.

If you do not hear back within 24 hours please eMail or phone 01494 471-762 (please check your junk eMail folder first - see below also).

Please add info@changingstates.co.uk into your eMail system's "safe list". Outlook users: Click here to add Changing States as a contact semi-automatically.

If you choose not to action as above (and sometimes even if you do) please check your "junk eMail" folder for responses.

eMails / phone calls to gather sufficient information are provided as part of the service (i.e. there is no additional charge).

No action will be taken without payment in advance via PayPal or cheque.


To book an appointment CLICK HERE or call 01494 471 762

Hypnosis and hypnotherapy High Wycombe and Central London

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© Changing States is a provider of hypnotherapy and hypnosis High Wycombe & Central London
Bill Frost - Clinical Hypnotherapist 1998-2017

Developed by: Neuro Innovations - providers of psychotherapy and EMDR software

Diplomate Member of the British Society of Clinical Hypnosis

Hypnotherapy High Wycombe | () | Hypnotherapy High Wycombe / Central London

Required disclaimer: Please be aware that we bring 100% of our effort and skill to the process, however, as with all practices, results may vary between individuals.