SUITABILITY ASSESSMENT FOR LINDEN ANXIETY RECOVERY
GUIDANCE ON COMPLETING THIS FORM
Please fill in the form to the best of your ability and click submit. This form will be sent directly to a Linden Method Specialist. All information is treated in the strictest of confidence and not passed to any third parties outside of our organisation.
If you are unsure whether our anxiety recovery program is suitable for you, please complete the form below and we will be back in touch to advise.
All Information is stored confidentially and in line with GDPR guidelines. All employees of The Linden Method abide by our Code of Ethics, for a copy of this or if you have any concerns or questions relating to policies, please email firstname.lastname@example.org
Person completing this form:
Age of sufferer
Name of sufferer
Which gender mostly describes you? (the sufferer).
Don't identify with any gender
Prefer not to say
Email address for correspondence
Mobile Number (we may use text to organise callback time)
Your nearest Town or City
Which Service are you interested in?
All Options include lifetime access to The Linden Method Program Portal
Online program inc Weekly Webinar (£179)
One Day Workshop in Worcestershire, UK (£695)
Four Day Residential Retreat, in Worcestershire, UK (£2950)
1-2-1 Zoom Coaching (5 sessions) (£795)
Junior Program for under 18s POA
Please tell us where you heard about The Linden Method program
Recommendation from a previous client
A Friend/Relative found out about it
Have you been diagnosed with anxiety disorder?
Have you ever been diagnosed with clinical depression?
Are you currently taking prescription medication for your anxiety disorder?
Have you ever had Cognitive Therapy? (CBT)
Are you receiving regular visits from Mental Health Services?
Have you received other talking therapy?
Have you ever been hospitalized for your condition?
Do you have any disabilities or medical conditions?
How long have you suffered from anxiety?
What do you spend most of your day doing?
Please be as honest as you can with your answers - This information will not be divulged to a third party. All of the symptoms and manifestations listed below are very common when you have an anxiety disorder but this list is by no means exhaustive. There are many others but that's not to say they don't exist within the realms of an anxiety disorder. This program is SOLUTION FOCUSED and treats the underlying anxiety and not the symptoms.
WHAT CONDITIONS DO YOU EXPERIENCE? PLEASE TICK ONLY BOXES THAT APPLY TO YOU.
Generalized Anxiety Disorder
Agoraphobia (not wanting to leave your perceived place of safety)
Monophobia (fear of being left alone)
Pure O (Disturbing Thoughts)
Post Traumatic Stress Disorder
Obsessive focus surrounding food
Social Anxiety Disorder
WHAT SYMPTOMS/SENSATIONS DO YOU EXPERIENCE? PLEASE TICK ONLY BOXES THAT APPLY TO YOU
Tightness in Chest
Headaches/Feeling like a band is around your head
Numbness, tingling in head
Tension/Pain in back, neck and shoulders
Heaviness/tingling in limbs/muscle pain
Smothering sensation/inability to take a deep breath
Excessive focus on breathing
Globus Hystericus (feels like lump/blockage in throat)
Skin blanching (paleness) or excessive blushing
Acid indigestion / reflux
Urgency to use the toilet
Irritable Bowel (IBS) Symptoms/Stomach Issues
WHAT THOUGHTS/FEELINGS DO YOU EXPERIENCE?
Anxiety about your health
Fear of death
Thoughts about existence
Compulsive thoughts / rituals
Fear of Failure (unable to make decisions)
Lack confidence/Feeling of not being good enough
Concerns about being judged by others
Feeling of guilt about the past
Loss of feelings of love for others
Very poor concentration
Feelings of being unable to cope
A sense of impending doom
A sense of living outside of your body
Are you currently receiving any therapy for your anxiety condition? If so, please give details of the type of therapy and frequency.
Are there any current, real life events that have caused your anxiety to increase. For example, relationship issues or separation, bereavement, employment issues, new baby etc.
If appropriate, please give details of how recent these events happened and if they are likely to be resolved anytime soon.
How do you want us to correspond ?
send information to my email address
text me an appointment time for a call
IMPORTANT… please read!
As with any form of Coaching, your commitment is key. The Linden Method program is SOLUTION FOCUSED. It is NOT about giving you management techniques or coping strategies. It is NOT about talking about your PAST. It is focused on taking you forward from the here and now and not looking and evaluating your past.
It is NOT what you've tried previously that has failed you. Our program will empower you, the sufferer, to help yourself and guide you towards full recovery. Ultimately, the only person that can fix you, is you! What you haven't appreciated yet is that you have a superpower (yes, you may not be think that right now, but you really do!). You haven't learnt how to harness it and instead of unlocking your brilliance, it is working against you (and providing 'oxygen' for the anxiety!)
We are often asked:
But this is my last chance at getting well and what if this doesn't work? What then?"
OK, so where do you think those "What if?" thoughts are coming from?
This will work if you engage in it, of that we are sure.
The Linden Method program will show you how to harness your superpower and empower you to navigate your roadmap to freedom from anxiety.
On a scale of one to five, please indicate how much of an impact anxiety has on your ability to function normally on a day to day basis
Coping day to day
How committed are you to getting your life back?
Form completed by:
By someone else on the sufferer's behalf
If completed by a third party
Relationship to sufferer
Is the sufferer aware you have contacted us
Have you ever been diagnosed with any other 'conditions' such as Aspergers, ADHD, Personality Disorder, etc.
Have you ever suffered from an eating disorder? If so, please give more details and state whether you have ever been hospitalised and if so, for how long and when were you discharged?
Are there any negative factors that are ongoing and having a negative impact on your mental health and wellbeing?