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Pre-Consultation Form

If you have been sent a link to this private page please fill in this pre-consultation form in as best you can and click SUBMIT at the bottom.

* Indicates required field

Name *

First

Last

Age *

Address *

Email *

Reason for Consultation *

How long has this been a problem? *

What makes it better? *

What makes it worse? *

Have you tried to make it better in the past? *

Doctor *

Surgery Address *

Medication / Other Treatment *

Current Health Status *

What do you specifically want from this session? *

How will you know when you have it? *

What has stopped you achieving this until now? *

What will be different in your life as a result of having these changes? *

How will these changes affect your friends, family and colleagues? *

Cash or cheque only
£80 one hour
£100 up to 90 minutes

Please arrive promptly / give 48 hours notice of cancellation

Contact: Angela Ralph
Tel: 07849 637281 Email: inspiringyork@gmail.com

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