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Name:

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Which City do you live in?

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Which Country do you live in?

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Email Address:

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What is the main Challenge you would like to address in your Healing Session?

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Where in your Body do you feel this Challenge?

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What is the Primary Emotion you Feel About this Challenge?

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When did you first notice this Challenge?

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Was there any significant Change, Trauma, Shock going on in your life at the time you first noticed this challenge? Please Describe...

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What were the main Emotions you felt about this Change, Trauma, Shock at the time? (if appropriate)

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How would you describe your life if you were free of this Challenge? Eg what would your ideal life look like?

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Describe how you would Feel if you could free yourself of this challenge and live this ideal life?

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Are there any other symptoms, challenges, background information, background etc that you feel may also be appropriate / relevant / related to maximizing the success of your Healing Session?

Thanks for entering the information. We look forward to catching up with you in your Healing Session. 

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