Ariel Daunay
New Client Questionnaire for Intensives
Full Name *
Your answer
Email Address *
Your answer
Address (City, State, Country) *
Your answer
I'm interested in: *
Required
I'm interested in: *
Required
Please briefly describe your physical symptoms (i.e. neck pain, shoulder pain, lower back pain): *
Your answer
Emotional symptoms (i.e. anxiety, stress, suffering, sorrow): *
Your answer
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): *
Your answer
Do you have any health concerns or long-term illnesses that you would like me to be aware of (i.e. cancer, diabetes)? *
Your answer
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