Appointment Form

Please note, as before commencing any therapy, it may be necessary to contact your GP prior to your first BWRT session.
Appointments must be made by the client themselves, 18+ years old only.

It is important you fill up the form in full, before we schedule your appointment.

← Back

Thank you. I will be in touch shortly.

First Name

Last Name

Phone Number

Email Address

Home Address

Date of Birth (DD/MM/YYYY)

Occupation

Marital status

Number and ages of children, if any

Sexual orientation

GP name and address
(It may be necessary to contact your GP before commencing the therapy)

Medical History:
diagnosis past and present, medications past and present

What is it you would like to be helped with?
Can you describe how it makes you feel?

Are you currently in therapy, either to address this challenge or anything else?
If so, please specify the therapy form as well as the issue you’re addressing and how long you’ve been doing it for.

What therapies and/or treatments have you tried in the past?
How helpful did you find them?

When is the best time to contact you to schedule your appointment?

How did you hear about Feel Your Best with BWRT?