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

Cell PhoneText MessageEmail
What is your relationship to the Liana Shanti Cult ?

I want to exit the Liana Shanti Cult and need help.I am a previous member of Liana Shanti's CultI have a family member in the CultI have a friend in the 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.

HMI Health CoachMother WoundFather WoundHealing from Narcissism12D Business SchoolLemurian Mystery SchoolLight Body ActivationAncient GiftsLife Path ManifestingNew Moon ManifestingFull Moon MotivationHMI Candida CleanseVarious HMI Courses and ProtocolsIlluminationsIlluminations 2Magnetic Money ManifestingImmunity MasterclassOther
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)*
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Liana Shanti Cult Recovery