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Tinnitus Assessment Booking form - Debbie Featherstone | www.debbiefeatherstone.com

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Tinnitus | Stress | Anxiety

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*

Country*

Other country:

Online assessment, preferred day:

Preferred time:

How did you find out about Debbie Featherstone?*

How long have you had tinnitus?*

How long has your tinnitus caused you distress?*

Other:

Where is the tinnitus?*

Is your tinnitus intermittent or present at all times?*

About your hearing

Where is your hearing loss?

I have hearing aids

Do you have HYPERACUSIS? (Sensitive to noise)*

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

Debbie Featherstone MSc Hearing Therapy | Psychotherapy & CBT Specialist

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