To help us create the best possible plan for your treatment, please answer the following questions as fully as possible. If any answer is “YES” please provide more information including when it occurred, severity level, any medication, dose and how long you have been taking it for.
Please allow 15-20 minutes to fill out the form below and ensure you have completed this a minimum of 24 hours before your session with us. If you are unable to complete this form for any reason please give us a call on 0272357100 to discuss. Failure to complete this form will result in your session being cancelled and you will be charged 100% of the session cost.