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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