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30 Day Grief Detox Questionnaire
IF YOU ARE SERIOUSLY CONSIDERING A 30 DAY GRIEF DETOX, PLEASE ANSWER THE FOLLOWING QUESTIONS TO SEE IF WORKING TOGETHER IS MUTUAL
24
Questions
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1
Human Name
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Please enter a valid phone number.
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4
Who are you grieving/ What has changed in your life?
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5
How are you currently coping with this change?
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6
What are your repeating thoughts about your experience?
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7
How are you currently feeling when you wake up?
*
This field is required.
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8
How are you currently feeling when you go to sleep?
*
This field is required.
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9
How would you like to feel on a daily basis?
*
This field is required.
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10
Are you willing to take Self Responsibility for how you feel?
*
This field is required.
YES
NO
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11
Are you willing to Journal Daily?
*
This field is required.
YES
NO
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12
Do you practice any of these mental health tools?
*
This field is required.
click all that apply
Journal
Meditation
Movement/yoga
Breathwork
Cold Bathing
Chanting
Alone "Me Time"
Spend Quality Time in Nature
Play Instrument
Cook your own meals
Exercise
Audio Record Yourself Speaking
N/A
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13
Do you have a weekly therapist or someone you can mentally check in with?
*
This field is required.
YES
NO
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14
Why are you considering this 30 Day Grief Detox?
*
This field is required.
What are your intentions for thinking about your life differently?
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15
Have you previously taken any online courses?
*
This field is required.
YES
NO
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16
If yes, was the online course beneficial for you?
please explain
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17
Are you aware YOU get to CHOOSE your own thoughts?
*
This field is required.
YES
NO
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18
Are you willing to NOT be on SOCIAL MEDIA for 30 days?
*
This field is required.
YES
NO
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19
Are you willing to explore sitting still with your discomfort?
*
This field is required.
AKA step out of your comfort zone?
YES
NO
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20
Are you willing to NOT watch the NEWS for 30 days?
*
This field is required.
YES
NO
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21
Is $444 for this 30 Day Grief Detox in your budget?
YES
NO
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22
How soon are you willing to start your 30 Day Grief Detox?
*
This field is required.
-
Date
Year
Month
Day
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23
How soon do you want to get on a phone call to see if working together is mutual?
Choose an ideal time and day for me to reach out to you.
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24
What are 3 things your grateful for today?
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