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What do you want to achieve or what caused you to reach out? What are you looking for in your life, that drew you to apply?
Where do you live? (City, State / Province, Country) *
Who referred you or how did you hear about us? *
Have you received a Life Activation YES/NO? If YES, how long has it been or when was it and with whom? *
If you're ready to move forward are you prepared to place a deposit?
Do you prefer to work with Dr. Theresa, or would you like a referral to a practitioner nearest you who is trained in the same lineage?
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