Derek O’Neill
Consultation Request Form

Your Name (required)

Your Email (required)

Your telephone number (please include country and area code) (required)

How would you prefer us to contact you?

By emailBy phone

Are you interested in a Private or Group Consultation?

PrivateGroup

Where are you based? (required)

Occupation

Presented issue (required)

Short medical history if associated with your presenting issue (required)

Other people you worked with on issue

What would be your ideal outcome from this work together? (required)

How did you hear about Derek's work? (required)

Have you attended any of Derek's workshops?

YesNo

Any other information you wish to include

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