Intake Application

Section 1: Contact Information

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Section 2: Primary Concern

What is the primary issue or symptom you would like support with?

How long have you been experiencing this concern?

Less than 3 months

3–12 months

1–3 years

More than 3 years

On a scale of 1–10, how much does this issue affect your daily life?

Have you received a medical diagnosis related to this concern?

What treatments, therapies, or approaches have you already tried?

Section 3: Impact

What activities would you like to do more easily if this issue improved?

Section 4: Root Causes and Contributing Factors

When did you first notice this issue?

Did anything significant happen around the time it began? Examples: Injury Surgery Pregnancy Major stress Illness Loss Other

Are there specific situations, foods, activities, or emotions that seem to make your symptoms worse?

What do you believe may be contributing to your current challenges?

Section 5: Goals

What outcome would make this experience successful for you?

If your symptoms were significantly improved, what would be different in your life?

Section 6: Readiness

Why are you seeking help now?

Which experience are you most interested in?

Releif Breakthrough

Comprehensive Breakthrough

Not Sure

Is there anything else you would like me to know before reviewing your application?

Are you prepared to invest in a personalized healing experience if we determine it is a good fit?

Yes

Possibly

No

Thank you for completing your application. Every submission is personally reviewed. If it appears that one of our healing experiences may be a good fit for your goals, you will be contacted regarding next steps.