First

Last Name

Country of Residence

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

Cell Phone, including country code

Native language and other languages spoken

Reason for inquiry

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

If employed, what is your profession/occupation? Where are you presently employed?

If you are a student, what degree are you working toward? What is your anticipted year of graduation?

Current living situation

Partner and or family Status

Age Required answer. Please check the corresponding age range

20-30

30-40

40-50

50-60

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- how you are limited 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

If you have had a history of alchohol/substance, please describe

Do any of the following conditions or circumstances apply

Severe depression

Suicidal ideation past 5 years

Suicidal ideation past 10 years

Suicide or self harm attempt

Significant untreated trauma

Treated trauma

If you checked any of the above, please explain

Additional comments

Contact

Anxiety Solutions

Remote Anxiety Specialty Treatment From the United States to Countries Across Europe Including:

United Kingdom

Netherlands

Germany

Sweden

Denmark

Spain

European Therapist Finders

International Therapist Directory

TherapyRoute European Directory

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