Booking Form | Piece Of Mind

First name

Last name

Preferred name

Phone

Preferred contact method (Email/Whatsapp/WeChat/Other)

What brings you to contact me today? (Multiple choice)

Learn more about my counselling services

Book an initial session

Interested in a specific topic (e.g., anxiety, insomnia, stress management, etc.)

Other (please specify)

Other reasons

Services you are interested in (Multiple choice)

Individual counselling

Hypnotherapy / Guided relaxation

Online sessions

Preferred date and time

Day

Month

Year

Time

HoursMinutes

Main concern(s) or goal(s) you would like to address in the session

Have you received counselling or therapy before?

How did you hear about me?

Any other information you would like me to know in advance? (e.g., language preference, accessibility needs, etc.)