Name *Contact Number *Email *What are your biggest FEARS? Describe *Who has been the most NEGATIVE INFLUENCE in your life? Describe *Who has been the most POSITIVE INFLUENCE in your life? Describe *What are your DREAMS That you want to ACHIEVE in your life? *Please describe in detail how you WANT to feelDo you believe in THE LAW of Attraction? (ie. are you the creator of your life?) and do you apply the Principals?Please describe the PRIORITY ISSUES you would like addressed I understand your services balance energy and that you do not not prscribe medications or diagnose disease. It is my own personal responsibility to accommodate whatever my body presentsand consult my health care provider if symptoms persist. I give my permission for future contact regarding related information via mail, email, text or phone. *AgreeSigned *Date *MessageSubmit
