Registration Form If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. First Name * Last Name * Address 1 * Address 2 * City * Post Code * Email * Phone Occupation * 1. List all prescription medication that you are currently taking and the conditions for which you take it: 2. Are you currently using any recreational drugs? 3. Have you ever been diagnosed with any of the following conditions? Depression Bi-polar Disorder Epilepsy OCD If yes, when? 4. Are you currently receiving any psychiatric treatment? If yes, under whose care and why? 5. Are you currently attending counselling or therapeutic treatments with another practitioner? If yes, under whose care and why? 6. Have you ever attempted suicide? If so, when? 7. Please provide the full name and address of your GP: 8. Please select if you give consent for me to contact your GP / Consultant should I deem it necessary? 9. What are your short-term goals? 10. What are your long-term goals? 11. What are your current family / living arrangements? 12. Any repetitive / vivid / familiar dreaming?