Private Evaluation Request
This form is not a booking and does not create any obligation.
Not all cases are accepted.
Full name
Email address
Phone (include country code)
What is the main phobia or fear blocking you right now? —Por favor, elige una opción—Fear of flyingClaustrophobia (elevators, tunnels, confined spaces)Situational panic attacksFear of drivingOther specific phobia
How long has this been happening?
What have you tried so far to resolve it?
How does this affect your life today?
Are you willing to do an intensive in-person intervention if there is a fit? —Por favor, elige una opción—Yes, I am willingNoNot sure yet
Anything important I should know before assessing your case? (optional)
I understand this service does not replace medical or psychiatric treatment and that my case will be reviewed before any intervention is accepted.
