Access Your Inner Wisdom

Application and Personal Data Record – Client Assessment Form

This form is only suitable for individuals who intend to set up an appointment, or who are in the process of scheduling a therapy session, not a consultation, with Kemila. It helps me understand your challenges and issues that we will work together on. Filling out this form online will save us some time of your first session. Thank you!

Or if you don’t like to do it online, you could also download the PDF file Application Personal Data Record, fill it out, and bring it to our first meeting.

* indicates required field

Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

To further assist you and save your time during our first session, after you’ve clicked on the above submit button, you will be directed to Suggestibility Quiestionnaires. It is to tell if you are more left brain or right brain dominant. Please take some minutes to do so.