Application Info Night

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1. Are you suffering from Chronic Health Problems right now?* This field is required.

Yes

No

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2. How long have you been suffering for?* This field is required.

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3. What were you diagnosed with (If you haven’t been diagnosed yet what do you believe you struggling with)?* This field is required.

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4. Before you got sick, briefly describe your typical daily activities and energy levels?* This field is required.

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5. Main symptoms?* This field is required.

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7. What do you feel you need help with the most?* This field is required.

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8. If we helped you over the next six to twelve months improve your health and wellbeing, what are three goals you would love to be able to achieve within that time?* This field is required.

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9. Do you believe that a holistic integrative approach is required to get results in regards to your Recovery. With the right , tools, frameworks and models, are you committed to working on different areas of your health and well-being to obtain the results you want?* This field is required.

Yes

No

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10. How important is this to you?* This field is required.

YES very important I am done going around in circles, it’s time to focus on myself! I want to get in the drivers seat so I am be an active participant in my recovery.

NO it’s not a priority right now.

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11. What’s your name?* This field is required.

First Name

Last Name

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12. What's your email?* This field is required.

example@example.com

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13. What's your Age?* This field is required.

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14. What country do you live in?

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15. What's your phone number?* This field is required.