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Name *

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Last

Phone *

Email *

In a nutshell describe your current situation and what you think the problem is. *

What would you like to accomplish? What are you trying to do? *

What would having that goal do for you? *

(How would that benefit you?)

What's your biggest challenge in attaining your goal? *

(What's stopping you from getting what you want?)

How is not getting what you want affecting you? *

What is the level of pain you are experiencing? 1-10 (10 being the most severe) *

Your level of pain also indicates the level of priority it is to resolve this issue in your life.

Main areas of pain? (Check All That Apply) *

Select areas would you like help with?

Have you had any traumatic memories that cause stress or tension now? *

What else have you tried before to address these issues?

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Monday - Saturday 9:00 am to 6:00 pm.
386 NW 3rd Avenue, Canby, OR 97013, USA, 503-862-9107

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