FEAR PHOBIA INFORMATION FORM

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電子郵件 *

Full Name *

Phone Number *

Occupation *

Please describe briefly your fear or phobia:

How long have you had this fear or phobia? *

What was happening in your life in the 3 months preceding the onset of your first phobic reaction? *

List three reasons why you want to overcome this fear or phobia: *

Have you tried to overcome your fear or phobia in the past? *

Yes

How did you try to overcome your fear or phobia? *

If applicable, why do you think you were not successful in overcoming your fear or phobia?

What situations trigger your phobia? *

Are there any specific instances when your phobia is worse than others? If so please describe below:

Do any of your family members suffer from a similar phobia? If yes please describe: *

Please describe any physical symptoms that your phobia produces *

In what way will your life improve when you have overcome the phobia? *

將我的回應複本寄給我。

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