Intake Form

Liana Shanti Cult Recovery

Intake Questionnaire
Contact Name

First NameLast Name
Cell Phone
Email
example@example.com
Reddit Online Username (Optional this helps us keep track)
Instagram Online Username (Optional this helps us keep track)
Preferred method of contact
What is your relationship to the Liana Shanti Cult ?
Address

Street Address (optional)

Street Address (optional)

City (Required)State / Province (Required)

Postal / Zip Code (optional)
Country (Required)
I have knowledge about the following Liana Shanti courses.

Other
Person involved with Liana Shanti Cult

First Name (required)Last Name (required)
Cult Members Akashic Name (Gifted)
Was this person involved in Young Living?
Are there children involved?
Are the children homeschooled?
Children(s) names (optional) with ages
Please explain what your concerns are and how we may help?
Do you consent to being contacted? (required)
Should be Empty:

Liana Shanti Cult Recovery