First and Last Name

Country of Residence

Cell Phone

native language and languages spoken

Reason for inquiry

How did you learn of my practice? Direct search? Through another platform? Recommendation?

If you live in the US, what is your state of residence

Employed or Student. If you are a student, what is your major and year of graduation

What is your profession/ occupation, if employed ?

Current living situation

Partner and or family Status

Age Required answer

20-30

30-40

40+

50+

60+

If Seeking treatment for OCD, please describe symptoms, age of onset, progress and changes over time, current severity or type N/A

If seeking for transport/travel anxiety please describe, onset, progression over time , type of travel/transport, impact on life or type N/A

If seeking treatment for another type of Anxiety Disorder, please describe in detail and include age of onset, progression over time, impact and severity or type N/A

Motivation or reason for seeking treatment at this point in time

Please describe current use of alcohol or any other substance

Additional comments

Anxiety Solutions

Age Required answer

Treatment of Anxiety and Obsessions

Working Remotely From

United Kingdom

Netherlands

Germany

Sweden

Denmark

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