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This video gives you some information on our free 15 minute chats.
Please fill in the below (only short answers required) and we
will contact you as soon as possible to arrange a free 15 minute
chat. The below is strictly confidential but helps us decide
which practitioner to book you in with if you decide to take
treatment with us after the free 15 minute chat.
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| Name: | |
| Male/Female: | |
| Address: | |
| Landline telephone: | |
| Mobile telephone: | |
| Email: | |
| Have you received and read our "Freedom from M.E. Information Pack"? |
Yes
No |
| If not, would you like our pack to be sent to you? |
Yes
No |
| Have you been diagnosed with M.E., C.F.S., Fibromyalgia or Lymes disease?
Please state which? |
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| What is your date of birth and how long have you been ill? |
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| Able to visit the clinic or interested in telephone treatment. Please state if help with access needed ie wheelchair/walking stick. |
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| What types of treatment have you had on the physical side of the condition outside
of the NHS –
e.g. nutritional therapy, homeopathy, acupuncture etc? Please state if
it was helpful or not. (No more than 150 words) |
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| Do you react badly to supplements? |
Yes
No |
What treatment have you had on the psychology side outside of the
NHS? For example have you done the Lightning Process, Mickel Therapy,
Reverse Therapy, Hypnosis, EFT, NLP etc. Please state if it was helpful
or not. Do you currently, or have you ever suffered with anxiety, depression, or any other emotional/psychological issues - please state which?
(No more than 150 words) |
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| Have you seen anyone that specialises in treating this illness physically? E.g.
Dr S Myhill, Dr J Teitelbaum, Dr A Wright, Dr R Perrin, Breakspear Clinic,
Dr De Meilier, Dr P Cheney, Dr J Mclaren Howard, Dr N Hembry, Dr B Puri etc.
Please state if it was helpful or not. (No more than 150 words) |
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| Do you have at least some limited funds available for treatment with
a practitioner, or are you looking for more general information, such as
details on our recovery group www.SecretsToRecovery.com? |
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| Would you like a 15 minute chat for: |
Psychology
Nutrition
Both |
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