Consult a psychologist
If you would like a consultation with the psychologist, please fill out this questionnaire.
Personal details
Personal name : Surname:
Age : 60+ 50s 40s 30s 20s teens not specified Sex male female Telephone
E-mail
Where are you? How did you find this site?
What service would you like? password to the advisory system and consultation by e-mail (fee payable) one face-to-face consultation - send me an appointment dynamic psychotherapy for a relationship problem cognitive-behavioural psychotherapy not sure
Problems : choose the most important problem, click that button. Use your own words in the box.
Relationships as a child Which statement best describes your relationship with your mother? I did not get on with her She looked after me, but did not make feel valued She made me feel loved She made me feel loved, but not capable I admired my mother's abilites, but did not feel close not specified Which statement best describes you and your father? He provided, but did not have much to do with me He made me feel loved and capable He taught me a lot I admired my father from a distance I did not get on with him There was nobody around I thought of as father My father hurt me deeply not specified How many brothers and sisters did you have? none one two three + My position is eldest middle youngest not specified Highest educational achievement (British system) postgraduate degree A-level professional qualification GCSEs (5+) GCSEs Less than GCSE not specified How much do you know about normal biology? I don't know much the human body More than a qualified nurse Some qualification e.g. A-level biology Good basic science e.g. GCSE Common sense, but no qualifications not specified
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 husband or wife partner I live with partner who has own home my brother my sister my best friend my son or daughter no close relationship not specified
Have you had any unpleasant events recently? If so, describe it in the box. no severe events death (spouse or child) death (friend or parent) bad accident assault major illness in relative major illness in self
How confident are you about rock-climbing, underwater swimming, or parachuting? I enjoy all challenges like this I will try some of these I am cautious about danger not specified How confident are you about giving speeches, acting or singing, or meeting VIPs? I enjoy all challenges like this I will try some of these I worry about looking a fool not specified A few words about your job
When you have finished, click submit to e-mail this questionnaire.
The information is not guaranteed to be confidential. Omit anything you might be embarrassed about.