Issue Category
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What best describes the primary issue you are seeking help with
Fear or Phobia
Anxiety or Stress
Trauma or Emotional Block
Allergies or Asthma
Chronic Pain
Medical Fear
Sleep Issues
Confidence or Self-Esteem
School/Learning Challenges
Relationship or Family Stress
Habit Change
Performance or Motivation
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Description of Issue
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In your own words, what is the problem you want help with? When does it happen, and how does it affect your daily life?
How is this impacting your life
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not much
Severely
On a scale of 1–10, how much does this impact your daily life?
Why now
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What prompted you to seek help now.
What is your desired Outcome?
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What would you like your life look like after we work together?
What have you Tried Before?
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What have you already tried to fix this? What worked or didn’t work?
What is the current cost
What is this issue emotionally, physically, or monetarily costing you at the moment?
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