SHAre YOUR Experience

Give Feedback + Share Your Story + Offer a Testimonial

I am very interested in hearing your story and your feedback about the work we have done together or how I might better serve you and future clients. Your feedback provides me opportunities to grow and develop as a practitioner and as a human being on this journey we all share. Please use the space provided to share your thoughts and/or suggestions. You will also have the option of allowing me to share what you have to say with others who may be wondering what people can experience through this work. I thank you for your consideration and your trust.

Feedback may also be provided via mail in form.

MAIL IN FORM +

NAME (optional)

You may leave this blank for anonymous submission

First Name

Last Name

E-MAIL (optional)

You may leave this black for anonymous submission

YOUR FEEDBACK: What would you like to share with me? What would you tell someone if they asked you about what it was like working with me? What has changed for you (since working with me)? What about this work or me surprised you the most? Is there anything I could do differently to better meet your needs or support you and others? Is there anything else you would like me to know?

You may fill out more than one form if you need additional space for your feedback, or select the printable form to return by mail.

MAY I SHARE?

Please indicate if you are willing to allow me to share your feedback with others. If you select "Share", please complete THE LEGAL STUFF section below.

Do Not Share

THE LEGAL STUFF

YOUR NAME AS YOU WISH IT TO APPEAR: If you are willing to allow me to share your feedback with others, please indicate your name as you wish it to occur and complete the release below. I will only share your feedback with your consent, as indicated by completion of the LEGAL STUFF section and the AGREEMENT below. Alteration to the name you provide in this field may occur, but will only ever be to give less identifying information (an abbreviation of name ie: use of initial/s rather than full name), unless express permission is granted. If you are only providing initials, your first, middle and last initials are helpful for differentiation of clients with identical first or last names and/or initials. Thank you.

Your name as you wish it to appear (or the maximum identifying information you are comfortable using)

AGREEMENT: I give my consent for Natalia Ronstadt Chang to publish my above-written feedback, together with the name/s I provide with my feedback or altered as outlined above (abbreviated, initials or any combination of the aforementioned), on her website www.nataliachang.com and any successor website, as well as on marketing materials for current and future healing or therapeutic energy practices she may engage in, on such page and in such position as she may determine at her sole discretion. I further agree that she may edit the feedback and publish edited or partial versions of the feedback, provided she never edit feedback in such a way as to create a misleading impression of my views. I may terminate this license by giving a 30 days’ written notice-of-termination. ELECTRONIC SIGNATURE: I have reviewed this document and fully understand and agree to its contents. I understand that this form is not a secure HIPAA document and that signing this form is voluntary, as is any information I have provided herein. I agree to submit this form electronically. I verify that I am the person whose name appears below and agree that my signature below is the legal equivalent to a manual signature on a document. My typed signature below, along with my submission of this electronic document signifies that I have read, understand, and agree to the terms and conditions herein.

ELECTRONIC SIGNATURE: Full legal name

Date

YYYY

“...a raft of respite in a rough sea. You allowed me to repair myself to meet the challenge of undiagnosed illness, loss of a parent and chronic pain. No one else ever offered me what you did!”

— Maureen E.

Please print this screen for your records, prior to submitting.

SHAre YOUR Experience

Give Feedback + Share Your Story + Offer a Testimonial

Location

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Distance Sessions Available

Contact

E-mail

Give Feedback

Other

FAQ

Forms & Policies

Share Yours

SHAre YOUR Experience

Give Feedback + Share Your Story + Offer a Testimonial

Location

MapDistance Sessions Available

Contact

E-mailGive Feedback

Other

FAQ

Forms & Policies

Map

Distance Sessions Available

E-mail

Give Feedback