Let us help | Very Therapy

First name

Last name

Email

Phone

Address

Have you had counselling before?

Yes

No

Tick all that apply

I've been feeling depressed

I feel anxious or overwhelmed

My mood is interfering with work/education

I struggle building or maintaining relationships

I can't find purpose or meaning

I am grieving

I have experienced a trauma

I need to talk about a specific challenge

I want to gain self confidence

I want to improve myself but don't know where to start

Just exploring

Experiencing panic attacks

When is last time you thought about suicide

How is you current sleep ?

Good

Fair

Poor

Please let us know about what is happening for you today that brought you to counselling

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