1:1 VIP Private Client

Congratulations for taking the next step towards achieving greater health, energy, and vitality!

You are about to embark on a journey that can literally
alter the course of your entire life!

I see this happening every day with my clients
and
This can happen for You Too!

***IMPORTANT*** Please Fill Out the Application Form Below Completely, and make sure to Hit Submit when finished.

We'll notify you BY EMAIL as to your next steps.

Congratulations on Taking Action!

Warmest Regards,

Debora

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Your Full Name*

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Childs Name (If Applicable)

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Your Age:

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INSTRUCTIONS: Please feel free to write as much as you want or need to. Don't worry about perfection. Just be honest. Really be open and transparent. Everything will be held strictly confidential and shared with no one.

Usually your first answers are the most honest and accurate answers, so don't over-think, don't over-analyze. Just read the questions thoroughly and answer immediately and honestly.

1. If you didn't have to figure out the "How To", describe what your health would look like, would be like, without stress and pain.

2. Why do you want to Break Free of Stress and Pain? Why is this even important to you?

3. How would your relationships, your job/career, your finances, your social life, your love life, your family be better if you resolved your health issues?

4.) What are your most urgent pains/problems/complaints/symptoms/illnesses/traumas or other issues that brought you here?

5.) What are any other problems/complaints/symptoms/illnesses/traumas that might not be as urgent, but that concern you?

6. How have these problems/complaints/symptoms/illnesses/traumas and issues affected the following areas of your life in a negative way:

Your Job/Work/School:

Your Intimate Relationships:

Your Relationships with Family & Friends and Your Social Life:

Your Finances:

Your Leisure and "Fun" Activities/Hobbies:

7. On A scale of 0-10 (10 being highest pain level ) what level is your pain or problem today? (This could be physical, mental, or emotional pain or problems)

8. How would you rate your level of satisfaction with your health the way things are right now on a scale of 0-10 (10 being my health is Great)?

9. What methods have you tried already in an attempt to change and get well?

10. What do you imagine your life will be like in 5 years if nothing changes from the way it currently is?

11. What is your MOST URGENT problem of all?

12.) What is stopping you from moving on from where you are now, and getting to where you would like your health to be?

13. What is the biggest challenge or obstacle in your way?

14. Is there any reason either conscious or unconscious that you can think of ...any part of you that may have a reason for NOT changing, for NOT getting healthy?

On a scale of 0-10 (10 being the most urgent) how urgent, how important is it for you to do something about your situation now?

16.) Which of these 3 describes you?

I am "Not Ready" yet to do anything about my health situation.I am "Getting Ready" to do something about my health situation.I am "Totally Ready" NOW to commit 100% and make my health a top priority.

On a Scale of 1-8 (8 being I am TOTALLY READY)
I am "Totally Ready" Now to Invest:

My Time

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

My Energy

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

My Money

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

My Heart and Soul To do Whatever it takes to Become Pain Free and Get My Life Back on Track!

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

DISCLAIMER: The information, materials, and attachments contained herein are designed for educational purposes only and may not be reproduced in any manner or format without specific written permission from Debora Wayne, LLC. This information is not designed or intended to provide guarantees of any kind nor to be considered medical advice, medical diagnosis, or medical treatment. Debora Wayne LLC, The Biofield Healing Institute®, International Chronic Pain Institute™ and any and all associates of Debora Wayne LLC, and/or The Biofield Healing Institute®, International Chronic Pain Institute™shall not be responsible or liable for any medical, financial, or other claims inferred from these materials. You are solely responsible for continuing with your own medical treatment and care. Any statements have not been evaluated by the Food and Drug Administration. Results are affected by a number of factors over which we have no control.

Thank you!
Remember to Complete the Form ENTIRELY, MAKE A COPY for yourself in case there are any technical difficulties, and then
HIT THE SUBMIT BUTTON NOW.
You'll be hearing from me shortly...Debora

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