First Name *

Last Name *

Reason for Wanting a DV *

I'm new to this type of therapy and not sure what to expect

I was let down by another therapist in the past and would like to see how good you are before I commit

I'm NOT sure if you can even help me

I'd like to get a feel for what you can do to help me BEFORE I commit to a full appointment

It's just easier for me to do it this way

What Are You Struggling With? *

What Does It Stop You From Doing? *

What Concerns You Most? *

How Long Have You Suffered or Worried? *

What Is the Main Goal You Would Like Us to Help You Achieve? *

Please tell us where to contact you with the outcome of the Free Discovery Visit application:

Phone *

Email *

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