Opening mid-June at Westfield London. Register your interest to be first to know. Email us

Pre-consultation form

Habit Change & Addiction

This form includes the AUDIT questionnaire (a WHO-validated alcohol screening tool) and questions about other substances or behaviours you'd like help with. We're not here to judge - we're here to help. Being honest on this form means your doctor can prepare the right support for you. Takes about 5 minutes.

~10 minutes 9 short sections Confidential
Just getting started 0 of 9 sections
Select all that apply.
Your age at the time.
How has your use affected family, friends, or partners?
SAFETY QUESTION: If you're having suicidal thoughts, please contact: Crisis support - Text SHOUT to 85258, or call 999 for emergency help.
Help us understand what brought you in today.
List all prescribed and over-the-counter medications.
Any additional information that might be helpful.

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name
Email
Phone
Date of birth

Primary Substance or Behaviour

What would you like help with? -
Age when you first started using or engaging with this: -
How long has your current pattern been going on? -

Consequences & Impact

What health problems have you experienced related to your use? -
Impact on relationships: -
Impact on work or studies: -
Financial impact: -
Have you had legal issues related to your use? -

Previous Treatment

Have you previously sought treatment or support for this? -
What's the longest period you've managed abstinence or controlled use? -

Mental Health & Other Conditions

Have you experienced depression? -
Have you experienced anxiety? -
Have you experienced PTSD or trauma? -
Have you been diagnosed with ADHD? -
Do you have chronic pain? -
Have you had thoughts of harming yourself? -

Readiness for Change

Where are you in terms of readiness to change? -
What's motivating you to seek help now? -
What support do you have available? -
What are your goals? -

Medications & Allergies

Current medications: -
Do you have any medication allergies? -

What You're Hoping For

What are you hoping to get from this consultation? -
Is there anything else you'd like the doctor to know? -
You can upload medical records, test results, or any documents relevant to your case (PDF, images, max 10MB).
Your information is sent securely to your doctor at LoveMyLife. We will not share your details with third parties. By submitting this form, you consent to LoveMyLife contacting you regarding your appointment.