Intake Form Private Sessions KABIRA
Hi, 

Thanks for considering, or booking a private trajectory with me.  
Before we start, please fill out this form. I will use your answers to get a better understanding of your situation, please include anything that might be relevant to our trajectory. 

Looking forward to start our journey. 

Warm regards,
Karlijn Kouwenhoven
 
info@withkabira.com 


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Email *
Full name *
Date of birth
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Gender
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Phone number *
Contact details in case of emergency (name + relationship + phone number) *
Current employment status / job 
Current relationship status
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Do you have any physical health conditions, injuries, or limitations that we should be aware of? If yes, please specify: *
Are you being, or have you been treated for any mental disorders? *
Are you taking any drugs, medication or alcohol? *
What overall grade would you give your life right now? *
How did you hear about KABIRA, Karlijn and the sessions?
What are some of the challenges that you are facing and what questions do you have? i.e. How can I... *
What are 3 things that you are hoping to achieve or gain from the session(s)? *
Any fears for the session(s)? If yes, please specify *
Is there any additional information you would like to share, or anything else we should know about you?
Are there anything specific questions that you have for me?
I have read and understood the Terms and Agreements (www.withkabira.com/terms-agreements/) *
Details for business invoice (only if relevant) 
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