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Is Energy Work Right For Me?
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Email
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Your email
Hey there! Have we met? If not, how did you find me (Discovery Healing: Emotion Code Practitioner's Map)? Referred (Family Member? A Friend? From a Client From Mine?) Please let me know below!
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Your answer
What is your full name?
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Your answer
How old are you?
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Your answer
What are your preferred pro-nouns?
She/Her
He/Him
They/Them
Clear selection
I would like to use Energy Work for:
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Physical Pain
Chronic Pain/Chronic Migraines
Physical/Mental/Emotional Trauma
PTSD/Any Traumatic Event
Abuse (Mental or Verbal, Emotional, Physical, Sexual)
Negative Self Talk/Beliefs of Self or Others
Rejection, Betrayal, Neglect or Abandonment
Self-Sabotage/Low Self-Esteem
Depression/Anxiety/Panic Attacks
Divorce/Relationship Problems
Grief/Loss of a Loved One
Anger
Fears, Obsessive Worrying or Phobias
Home, Work, or Chronic Stress or Fatigue
Other:
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Are you experiencing any physical pain today?
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Yes
No
If you chose "Yes" to the question above, what is the severity of your PHYSICAL pain level today? (On a scale to 0 to 10, 0 being NO pain and 10 being the WORST pain you ever felt in your life):
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Do you suffer from chronic pain?
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If you suffer from chronic pain, what is your pain levels on any given day? (On a scale to 0 to 10, 0 being NO pain and 10 being the WORST pain you ever felt in your life):
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Do you suffer from chronic migraines?
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If you suffer from Chronic Migraines, how much do these effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "PTSD/Any Traumatic Event," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Abuse (Mental or Verbal, Emotional, Physical, Sexual)," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Negative Self Talk/Beliefs of Self or Others," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Rejection, Betrayal, Neglect or Abandonment," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Self-Sabotage/Low Self-Esteem," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Depression/Anxiety/Panic Attacks," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Divorce/Relationship Problems," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Grief/Loss of a Loved One," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Anger," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Fears, Obsessive Worrying or Phobias," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
If you chose "Home, Work, or Chronic Stress or Fatigue," how much does this effect your life on a daily basis: (0 being NO EFFECT and 10 being DEEPLY EFFECTED/DEBILITATING YOUR LIFE):
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Clear selection
How do you hope to feel after doing energy work?
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Your answer
Jessica will reach out to you after your submission is complete - what is the best way for her to contact you (Facebook- Messenger App, E-Mail, Instagram, etc.)?
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Your answer
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