Tinnitus Assessment Booking form - Debbie Featherstone | www.debbiefeatherstone.com
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Why CBT
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Tinnitus | Stress | Anxiety
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Please complete this Assessment Booking form if you are looking for help and would like to be contacted by email
I am looking for help to manage my tinnitus. Please tick all appropriate boxes
I am looking for help
I would like to book an assessment
I would like to have more contact by email before I decide
Other. Please state in the box:
Date*
Name*
Your email*
Mobile Tel Number
Age*
Gender*
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Male
Female
Country*
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England
Scotland
Wales
N. Ireland
USA
Australia
Other country e.g. France, Spain etc. Please state:
Other country:
Online assessment, preferred day:
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Monday
Tuesday
Wednesday
Thursday
Friday
Preferred time:
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Morning
Afternoon
Late afternoon/evening LATEST 7.00pm UK time
How did you find out about Debbie Featherstone?*
How long have you had tinnitus?*
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Less than 3 months
3-6 months
6-12 months
1 - 2 years
2 - 5 years
5 - 10 years
More than 10 years
How long has your tinnitus caused you distress?*
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From the time it started
Only for the past month
For less than 6 months
Other. Please state
Other:
Where is the tinnitus?*
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Left side only
Right side only
Left and right sides
Both sides and in the head
In the head
Other. Please state:
Is your tinnitus intermittent or present at all times?*
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Intermittent
Present at all times
Other. Please state:
About your hearing
*
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I have normal hearing
I have hearing loss
Where is your hearing loss?
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Left ear only
Right ear only
Both ears
I have hearing aids
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Left ear only
Right ear only
Both ears
I have hearing aids but I don't like wearing them
Do you have HYPERACUSIS? (Sensitive to noise)*
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Yes
No
I don't know
What services have you accessed so far?
None
GP
ENT
Audiology (NHS-UK)
Audiology (Private)
Hearing Therapy (UK only)
Please tell us about other services you have accessed
In your own words, tell us about your experiences of the help you have received
Thank you for completing your Mini History & Assessment Booking form. Your mobile number is only used for confirmations by text and where emails have failed to reach you. ALWAYS CHECK YOUR SPAM FOLDER WHERE NO REPLY ARRIVES IN YOUR INBOX
When you press SEND you will receive a copy of your responses by email and I will get back to you as quickly as possible by email - please check your Spam folder if an email does not arrive in your Inbox
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