Ascension369 - Client Intake Form

Name*

First NameLast Name

Birth Date*

MonthDayYear

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about me? *

1. What are your main concerns with health & spiritual rituals?*

2. What have you done in the past to work on these health condition & spiritual rituals? (include both alternative and traditional modalities.)*

3. What has proven effective?*

4. What is your current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.*

5. What would you like your health & spiritual rituals to be 30-days from now? *

6. How about 90-days from now? How would you feel if you got this result?*

7. What obstacles, challenges, and struggles do you come up with regarding health/lifestyle/spirituality?*

8. How much of a priority is this to make a change for yourself? (0-Not Important to 5-Super Important!)

9. The price of this program is a significant investment, is this something you're willing to look into to transform your life?

10. What do you intend to get out of our time together?*

Please let me know a 2-3 days and times you're available to meet online?

I'm excited to help you breakthrough what's been stopping you and holding you back from awakening your true potential. I'll be reaching out to you soon to get started!

Please allow up to 48-hours for a response.

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Ascension369 Application