Appointment Form
Required fields are marked with an *
| Name* |
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| Email* |
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| Address |
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| City |
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| State/Province* |
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| Zip/Postal
Code |
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| Phone Number* |
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| Country* |
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| Best time to call you?* |
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| Your Time Zone?* |
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| Referred by...? |
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| I have read and understood
the no-risk
policy* |
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The Submit button is at the bottom of this
page.
We will be contacting you to schedule an appointment. However,
by filling out the details below, you will save time (and money)
in your first session, as we require background information about
your challenge in order to help you with it. We will briefly go
over this information with you during the first session to make
sure we understand it completely.
You are not required to complete the questions below, but we
encourage you to do so.
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| Main challenges. Please
check those that apply |
| Relationships |
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Career |
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Physical Health |
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| Finances |
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Emotional Health |
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Pet / Animal Issue(s) |
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| Other |
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If you checked 'Other'
please explain below: |
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| Have you worked with
other professionals on the issue(s)? |
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| If 'Yes', please indicate below which
types of professionals . |
| M.D. |
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psychotherapist |
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holistic doctor |
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| chiropractor |
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naturopath |
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energy healer |
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other |
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| What were your overall results when
working with other practitioners? |
| Excellent |
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Average |
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Poor |
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| None |
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Good, but not permanent |
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| Do you feel totally committed
to doing whatever it takes to resolve this issue, whether it means
changing work, money, or other areas? |
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| Are you interested in
taking responsibility for your situation by doing things for yourself,
such as learning a simple therapy, taking supplements, practicing
visualization or other types of 'homework' if we deem them to
be helpful? |
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| Have you had experience
with energy- or intuition-based therapies? |
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| If 'Yes' please list the
types of therapies below |
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| What percentage of your problem do
you feel is due to external causes (meaning they have nothing
to do with you)? |
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