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Therapy with Liz PSYCHOTHERAPY IN SOUTH MANCHESTER & ONLINE

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Registration Form

This online form serves as the starting point for online therapy and helps us to prepare for the first session.


Fill out as much information below as possible, making sure you provide a contact email address and phone number.






Personal Information























Marital Status (select one option)



  • Requested Therapy Format Information



    What is your preferred method for online therapy? (select one option)






  • What device will you be using for online therapy sessions? (select one option)

  • Please note that the use of mobile phones for online sessions is not advised as the internet connection is not stable enough for the 50-minutes that online therapy sessions take.


    Please select all that you have experience with (select all relevant options)



  • Would you like to receive reminders and confirmations for psychotherapy and counselling appointments? (select one option)



  • Emergency Contact and Health Information






















    Background Information


    Have you received psychotherapy or counselling in the past?





  • Have you been prescribed any psychotropic medications (e.g. anti-anxiety or anti-depressant medication)?











  • Have you ever been an in-patient in a hospital or unit for any of the following (select all relevant options)
































  • Were you ever physically or sexually abused as a child?





  • Have you ever felt in the past like harming yourself or somebody else?


  • If so, do you have those feelings now?






  • Marketing


    I occasionally send out news and information in an email newsletter. Please indicate if you would like to receive this newsletter.







  • Once you have completed your details please send your form below. I will review the information and contact you within 48 hours, to discuss any details that need clarification and to arrange booking your initial consultation session.


         




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