Crystal Clear Healing Assessment Application
Are you ready to discover your Ultimate Healing Potential?
So we can make the best use of our time together in your Crystal Clear Healing Assessment, please fill out the form below. This way, I get to know more about you and then we can spend the entire time on your healing assessment.
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Email *
Name *
Phone *
How did you find me? *
Required
Describe your current situation. What brings you to me? *
How long have you been experiencing this current situation? *
What do you most want to change today? *
If you have you tried to change this before, what have you attempted that didn't work? Why? *
On a scale of 1-10, how important is it for you to achieve change today? *
Least important
Most important
On a scale of 1-10, 1 being the lowest, how committed are you to accomplishing your needs and reaching your goal?
lowest level of commitment
highest level of commitment
Clear selection
Do you currently: *
Is there anything else? Please let me know if you have any pressing questions or concerns.
Would you like to receive my newsletter? If so, Check the topics that interest you. *
Required
Thank you
Once I receive this information, we'll be ready for your first appointment - a Crystal Clear Healing Assessment. Based on our conversation, you'll receive a follow-up message with further options and/or instructions.
Thank you so much for for taking the time to answer this brief survey. I look forward to speaking with you.

Regards,
Rosemary Levesque
www.SecondNatureHealing.com

*NOTE - we do not diagnose, treat, or cure disease. Our conversation and your assessment are for educational purposes so that you may make choices for your personal natural healing.
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