EmailMe Form - APPLICATION PRIVATE APPOINTMENT

APPLICATION PRIVATE APPOINTMENT - UNDER 18

Ideally to be completed by the sufferer if of a suitable age and level of maturity but if not, by the parent/guardian.

Please complete all questions and press submit. You only need to take 10 minutes and please don't worry about spellings or grammar, its not an english test!

We abide by GDPR data protection laws All information is held in the STRICTEST CONFIDENCE. This information is not shared with any third parties and will be securely destroyed after the telephone consultation if you do not join the program. If you join the program the information may be retained for the duration of the support period (12 months).

You have a right to request any information that is stored by us, at any time, by sending a Subject Information Request to julie@thelindencentre.org

If you wish to view our Privacy Policy, please visit our website:
www.thelindenmethod.co.uk

Name *
First Last
Parent/Guardian Name *
First Last
Year of birth *
Country of Residence *
What day and time is best for your appointments? *
Telephone number inc country code *
What Gender do you most identify with? *
Female
Male
Male transitioning to Female
Female transitioning to Male
Gender Neutral
Parent/Guardian Email *

Confirm your email address
Please be as honest as you can with your answers - This information will not be divulged to a third party.
If you reside in the UK are you currently under CAMHS? If outside of the UK, any other mental health organisation? Please give details. *
Are you aware of a catalyst that started set off the anxiety? *
is that situation/event still ongoing? *
Have you had any talking therapy or CBT? If yes, please give details of the type of therapy, approximate dates and length of therapy. *
Are you in full time education? *
What do you spend most of your days doing? *
Do you use alcholol or drugs in order to cope with your anxiety? If yes, please provide more details of what you use and how often. *
Do any other members of the family suffer (or have suffered) with an anxiety condition? *
Your Symptoms and Behaviours
Tick the ones you are struggling with

What symptoms of anxiety does your child experience?

	YES
Generalized Anxiety Disorder
Panic Attacks
Agoraphobia (fear of leaving your 'safe place'
Monophobia (fear of being alone)
Separation anxiety
Emetophobia (fear of vomiting)
OCD (Obsessive Compulsive Disorder)
Post Traumatic Stress Disorder
Social Anxiety Disorder
Health Anxiety
Pure O (Disburbing thoughts)
Self-Harming
Low mood
Fear of dying
School Phobia
Anger issues
Insomnia

Has you ever suffered from an eating disorder. If so, please give more details and state whether they have ever been hospitalised and if so, for how long and when?
Have you been diagnosed with any other 'conditions', such as Autistic Spectrum Disorders, ADHD, Dyslexia, Personality Disorder, etc?
(We don't like giving children 'labels' as we feel they are labelled too readily these days, but we have to ask the question).
Are there any negative factors that are ongoing and having a negative impact on your mental health?
Please identify which are the most overwhelming symptoms or conditions.
Any other information that would be useful in order for us to assess the suitability of the program for you?
YES

Do you take medication for the anxiety?

Do you suffer from diabetes or other endocrine disorders?

	YES
Do you take medication for the anxiety?
Do you suffer from diabetes or other endocrine disorders?

TICK THE ONES THAT YOU RELATE TO. THE ANXIETY ...

	YES
Is ruining my life and I need it to be gone
Is a constant negative infuence
removes my ability to make any decisions
is holding me back from achieving what I know I am capable of
has made me withdraw from everyone and everything
means I have to act as though everything is OK when really I am NOT
has taken away my confidence and made me feel alone
is constantly there but not really stopping me from doing everyday things
is manageable and not always there
is uncomfortable but I'm afraid to let it go
is bothering my parents more than its bothering me

I accept the Terms and Conditions and understand that The Linden Centre team will not be providing counselling or talking therapy, but instead provide guidance and support for the implementation of The Linden Method anxiety recovery program. *
TICK BOX
On a scale of 1 to 10, how committed are you to implementing this program to get your life back? *

Not sure
1

2

3

4

5

6

7

8

9

10

Bring it on!
Form completed by
Clear
I am :
The sufferer
Parent/Grandparent/Guardian
A concerned friend of the sufferer

Your assessment will be handled by an accredited Anxiety Recovery Expert.

Your Symptoms and Behaviours