Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Preferred Contact MethodEmailPhoneSMSWhatsAppWhat brings you here today? (You can choose more than one)PTSDTrauma related to a single eventChildhood traumaAnxiety / panicFlashbacks / intrusive memoriesNightmaresPhobiasOtherIf you selected “Other”, please describe:Briefly describe the issue (one sentence only):No need to go into detail or relive the trauma.How intense does the problem feel right now? (0 = none, 10 = extreme) *— Select Choice —012345678910How long has this affected you?Less than 6 months6–12 months1–3 years3–10 yearsOver 10 yearsHow does this affect your daily life? (multi-select)SleepWorkRelationshipsMoodAvoidanceConfidencePhysical symptoms (tension, stomach, heart racing)OtherPrevious Therapy?YesNo achieve know? Therapy? If yes, what type of therapy/support?Current Medical/Psychological SupportYesNoPlease specify (optional)What would you like to achieve from Rewind Therapy? *Anything else you’d like me to know?Have you ever received a formal PTSD diagnosis? (Optional — this does NOT affect your ability to receive Rewind Therapy.)YesNoPrefer not to sayUnsureSubmit
