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Enquiry Form
Who is this enquiry for?
*
Adult with tics (18+)
Young person with tics (under 18)
Other
Your Name
*
Clients name if differnt
Clients Date of Birth
*
Day
Month
Year
Email
*
Phone
*
How would you describe your/the client’s current tic experience? (Multiple choice – select all that apply)
*
Mainly movement/motor tics
Mainly sound/vocal tics
Both motor and vocal tics
Complex tics or tic clusters
Functional tic-like behaviors (sudden onset tics)
How much are tics currently impacting daily life?
*
0–2 = Mild
3–5 = Moderate
6–8 = Significant
9–10 = Severe
Other areas you may want to support (tick any that apply):
*
Anxiety
ADHD
Autism
OCD
Sensory Processing Differences
Executive Function Support
Self-esteem/Confidence Building
School or Workplace Advocacy
Emotional Regulation Skills
Previous Support or Diagnosis
*
Main Goals for Therapy:
*
How did you hear about Tictock Therapy?
Anything else you’d like to share with us?
*
Preferred Appointment Day - select all
Monday
Tuesday
Wednesday
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