Three Step Rewind Client Questionnaire

Thank you for inviting me to support you with the Three Step Rewind technique. Rewind is a well-established technique which works with our normal human processes to unhook an unwanted emotional or physical response from a difficult experience. Rewind isn’t therapy and I am not a therapist. The purpose of the technique is to unhook the experience from our own innate alarm system. You will retain the memory of the experience, that is very important, but hopefully the difficult feelings that come up around the experience will be eased.

All responses and information shared during our discussions are strictly confidential and all paperwork including this completed form are kept in accordance with GDPR regulations. Please complete and return this form a minimum of 24 hours before your first session to enable me time to prepare for our time together. If you experience any issues with this form, please email me at info@themilkhub.co.uk

Name *

First

Last

Are you attending a face-to-face consultation or a virtual consultation?

Face-to-face consultation (please ensure you complete the Covid-19 questions at the end of the form)
Virtual consultation

What are your preferred pronouns for yourself and your family?

Your telephone number *

Your email address *

Your Address *

What is the name of your partner/supporter?

What is your relationship to your named partner/supporter? E.g wife, husband, partner, friend, parent etc.

Can you tell me a little about the experience you would like to work on in our sessions together? If you would prefer not to share this information, there is no pressure to do so, the Rewind technique can be used successfully without sharing details of your experience.

Are there any other services or professionals you as a family are currently working with? *

For example; Early Help, Perinatal Mental Health, Childrens Social Care, Home Start, Your Family, Infant Feeding Team etc.

Are there any health concerns for you or anyone in your immediate family that we should be aware of? *

Is there anything else you would like to share with me?

By completing and submitting this questionnaire you are giving permission for The Milk Hub to collect and process the above information including any personal information as defined under GDPR regulations, and in line with both our legitimate interests. All information you supply is held in the strictest confidence and not shared with any third parties without your consent. The only exception to this is if we are required to disclose information to another agency or service in line with a safeguarding concern. Completing and submitting this questionnaire also acknowledges that you accept the Privacy Notice, Terms and Conditions and Safeguarding Policy listed on The Milk Hub website. *

I agree

If I am attending a face-to-face consultation, I confirm the following information:

No one in my household (including myself) is experiencing any Covid-19 symtoms
No one in my household (including myself) has had any contact with anyone with Covid-19 in the last 14 days
No one in my household (including myself) has been asked to self-isolate
No one in my household (including myself) has travelled abroad within the last 14 days

You will be asked to confirm the above information again, the day before your appointment. In the event of one or more of the above conditions not being met, a face-to-face appointment will not be able to take place. A virtual appointment will be offered to you at the same time.

Three Step Rewind Client Questionnaire

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