Private Sessions Form

Childless.Life Private Sessions

Thank you for your interest in private sessions. To better understand your unique needs, please complete the following questionnaire. If you are uncomfortable with any (non mandatory) question please skip and we can discuss it together.

Contact Information

First name

Last name

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Phone

Birthday

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Information

Emergency Contact Full Name

Relationship

Phone

Health

How is your current physical health?

Are you currently experiencing any chronic pain?

Yes

How is your current mental health?

Are you currently experiencing anxiety, panics attacks or have any phobias?

Yes

Do you engage in any behaviours for emotional comfort, numbing or soothing that might have negative consequences (such as emotional eating, recreational drug use, over working, etc)

Yes