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Karen Shirlow

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SERVICES

First Name

Last Name

Email

Would you consider your issue:

Acute (Indentified Single Issue)

Chronic (Longterm Complex State)

Would you describe your Symptoms as:

Trauma

Anxiety

Depression

Grief

Phobia

Other

How long have you been experiencing these symptoms?

Less than 1 year

1 - 5 years

6 - 10 Years

10 + Years

Are you aware of a specific experience or event which may have triggered your symptoms?

Yes

No

Perhaps

Are there other experiences in your past which may have impacted you emotionally?

Yes

No

Perhaps

What is your greatest fear in life?

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