Private Session Questionnaire

Date*

Date Format: MM slash DD slash YYYY

Name*

First Last

Month, Day, Year and Time of Birth*

City and Country of Birth*

Phone (Day)*

Phone (Evening)*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

What do you do for a living?*

How did you hear about Dr. Nataleah?*

Have you attended an event facilitated by Dr. Nataleah?*

Yes
No

Have you previously had an appointment with Dr. Nataleah?*

Yes
No

In detail, describe why have you chosen to request an appointment. Please include any challenges and issues you feel you are facing, as well as any previous healing work you have pursued.*

Are you currently receiving any type of therapeutic support? If so, provide a short description.

i.e. from a counsellor, psychiatrist, psychologist, social worker

Are you currently taking any prescription medication? If so, list below and include its purpose.

Have you read and understood the Appointment description on our website?*

Yes
No

Online sessions are held by Skype or Zoom. If you have Skype, what is your username?

What is your preferred appointment time?*

Afternoons
Evenings
Weekends

I understand that once a session is booked, there are no cancellations or refunds.*

Yes
No

I understand that any information given in this private session is offered for its suggestive and informative value. I agree to accept full responsibility for the practical application of the information provided.*

Yes
No

I understand that my private session will be recorded and that some content may be used for educational and research purposes with all personal information remaining private and held in strict confidence.*

Yes
No

Private Session Questionnaire

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