Full Name:
Address:
Phone:
Email:
What appeals to you about our workshop?
Do you have any specific interests or issues you would like to address?
What healing modalities have you done in the past, if any? Results?
Do you have any health issues we should be aware of?
Are you currently on any medications (prescribed or otherwise)?
Describe your past and present home life.
Have you adopted a religion or spiritual understanding?
What are your goals for this workshop?
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