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What Problems would you like to solve?

More confidence Reduce Stress Improve decision-making skills More powerful communication Reduce stress of business presentations Accelerated learning techniques Improve exam performance New self-image Managing depression Overcome a phobia Overcome panic attacks Reduce worry and anxiety Stop smoking Weight loss Insomnia Imrove relationships and enhance relationship skills Rapport building skills Dealing with expatriate resettlement Relaxation and positive thinking to aid fertility Self-hypnosis Achieve a more positive outlook Help find a new direction for your life Begin to live the life you really want None of the above

If none of the above, please specify:

Key reasons for trying to find a solution now:

New year\'s resolution Lifestyle change Spur of the moment None of the above

If none of the above, please specify:

What has stopped you from tackling the issue in the past?

Never been as bad Never accepted it as part of my life It\'s got more urgent to solve quite recently None of the above

If none of the above, please specify:

Have you ever visited a therapist before?

Yes No

If yes, which therapy?

Psychotherapy Hypnotherapy Psychoanalysis Psychiatry Reflexology Shiatsu massage Aromatherapy Indian head massage None of the above

If none of the above, please specify:

How many sessions do you expect treatment to take?

1 to 2 sessions 3 to 5 sessions 6 to 10 sessions More than 10 sessions

Do you think that the cost of the treatment is:

About right Too expensive Less than I expected

Would you like to be contacted regarding regular seminars and special offers?

Yes No

Which Newspapers do you read?

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Where do you live?

What is your nationality?

Where did you hear about this website?

On-line search Link from another website Magazine Radio ad Poster Leaflet Yellow Pages Newspaper article Newsagent\'s window Personal recommendation

Please be more specific, ie: which newspaper, radio station etc?

Do you intend to book an appointment with the therapist?

Immediately Within the next month Within the next 3 months Yes but can\'t say when No I won\'t be booking a session

If you answered no, please specify why not: