Empowering Transformation: An Integrative Program for Chronic Lyme and Autoimmune Disorders *Application* Due April 18th, 2018
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Email Address:
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Date of Birth:
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Emergency Contact:
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Emergency Contact Phone #:
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How did you find out about this program and what interests you specifically about participating?
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Have you ever worked with a coach or therapist before? What was your experience like?
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What is your health history (in chronological order as best as possible)? *
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What are your main stressors (relationship, work, chemical, financial, familial, etc)?
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What have you been told you have been diagnosed, tested positive for, etc?
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What modalities have you been exploring or treating with?
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What have you felt has worked for you and what has not?
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List the major accidents, traumas that you have had?
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How much are you desiring to be healthy?
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What are your current health goals? And what has inhibited you thus far from reaching them?
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