Name *

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Country * none selectedAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte D'IvoireCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic People's Republic of KoreaDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar(Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern IrelandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaRéunionRéunionSào Tomé And PríncipeSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaScotlandSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard & Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWalesWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

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Profession *

I was referred by *

Date of Birth *

Participation as: * Select ...ClientSupportTrainee

Please share your healing request/ area of inquiry? *

Are you experiencing any of the following: * Are you experiencing any of the following: *
 Depression
 Dissociation
 Chronic Stress
 Compulsive Behavior(s)
 Anger
 Compulsive Behavior
 Negative Self Talk
 Shame
 Mood Swings
 Chronic Bad Luck
 Post Traumatic Stress
 Panic or Anxiety Attacks
 Sleep disruptions
 Alcoholism
 Drug Use
 Chronic Illness
 Sense of something missing
 Procrastination
 Paranormal Experience
 Traumatic Loss
 None
 Other

Do you currently have any chronic conditions? *

Have you experienced therapy before? If yes, when was it? For how long? And what Modality?  *

Are you taking any medications? * yes
no

For what purpose do you take medication? *

What kind of support do you currently receive? * Psychotherapy
Bodywork
Massage
Energywork: reiki, healing touch, etc
Shamanic Work
Acupuncture
Homeopathy
Medical
something else

May I connect with your support team? * yes
no

I agree to hold confidentiality throughout and beyond our meeting time. * Select ...YesNo

I understand that all payment are non-refundable in nature. * Select ...YesNo

Would you like to join our email list? * Select ...YesNo

Is there anything else you wish to share?