Healing for Women with Complex Chronic Illness(HWCCI): Application
Application for 12 week Online Program
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What is your name?  *
Email address:
Phone number:
What is your preferred method of communication?
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Why are you interested in the HWCCI Program with Dr. Kristin Renner? *
Please list any health conditions or diagnoses you have received. If you don't have any official diagnoses that's okay. *
Please describe your full health history as succinctly as you can. *
What treatments or programs have you tried thus far? *
What are the most pressing health concerns for you at this time. Please order these from most important to least important. *
What would you life look like/how would your life be different if your health was not an issue or you didn't experience the symptoms you have now? *
What are your health goals? *
How motivated are you to put effort into your own healing? *
Not very motivated.
Extremely motivated.

Are there any barriers you could foresee being an issue or disrupting your ability to reach your health goals? Please list in order of importance. 
Is there anything else you would like Dr. Kristin Renner to know about you? *
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