Consult a psychologist

If you would like a consultation with the psychologist, please fill out this questionnaire.
A return e-mail address is essential if you want a reply.

Personal details

Personal name : Surname :

Age : Sex     E-mail     Telephone

Where are you?      How did you find this site?     

     
What service would you like?

Problems :  choose the most important problem, click that button. Use your own words in the box. 
  • anxiety about many things
  • panic attacks
  • depression
  • dissatisfied with weight or appearance
  • intrusive thoughts and images
  • persistent pain
  • managing a physical illness
  • difficulty in a close relationship
  • expression of anger

Relationships as a child

Which statement best describes your relationship with your mother?

Which statement best describes you and your father?

How many brothers and sisters did you have?    My position is

Highest educational achievement (British system)   

How much do you know about normal biology?  
Current situation

Select one relationship from the pull-down. Give some comments about closeness, separation, and how you deal with conflict and anger
My most intimate relationship is

Have you had any unpleasant events recently? 
If so, describe it in the box. 

How confident are you about rock-climbing, underwater swimming, or parachuting?

How confident are you about giving speeches, acting or singing, or meeting VIPs?

A few words about your job  
When you have finished, make sure you have included a return address. Then click submit to e-mail this questionnaire.
The information is not guaranteed to be confidential. Omit anything you might be embarrassed about. 
If you do not get a reply within 5 days, copy the data from this form and paste it into your own e-mail.
E-mail to econduit@cpsych.org.uk. The backup address is econduit@yahoo.com