Client Application
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Full Name *
Email *
Gender
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Cell Phone Number
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Date of Birth / Age
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How did you hear about us? *
What is your level of commitment?
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What's holding you back from a full, happy, vibrant life?
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Required
How well does your family and/or spouse support your decisions regarding your health and life quality?
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Are you in a position to make a significant financial commitment to your health?
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Do you exercise?
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What type of exercise do you do?
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How long have you consistently exercised?
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How many days a week do you exercise?
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Do you practice meditation?
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Have you consistently practiced any type of deep breathing method?
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Do you practice sleep hygiene?
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Do you actively limit your EMF exposure?
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Do you make sure to get sun exposure w/o sunscreen daily?
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Do you practice grounding/earthing?
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Have you ever dieted?
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Do you consider yourself coachable?
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When are you looking to start your program to get the health you truly want?
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Is there anything that you’d like us to know about your case?
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Last question-was this survey too long?
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