Ariel Daunay
New Client Questionnaire for Intensives
Full Name
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Email Address
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Address (City, State, Country)
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I'm interested in:
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I'm interested in:
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Please briefly describe your physical symptoms (i.e. neck pain, shoulder pain, lower back pain):
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Emotional symptoms (i.e. anxiety, stress, suffering, sorrow):
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Psychological symptoms (i.e. repetitive thinking, narrow conclusions about yourself and the world around you):
Your answer
Relational symptoms (fear of physical contact, issues communicating with your partner):
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Do you have any health concerns or long-term illnesses that you would like me to be aware of (i.e. cancer, diabetes)?
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