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Name: First, Last *

 
Email address: *

 
Phone number: *

please include area code
 
What is your main concern or problem and how long have you been dealing with it? *

 
What frustrates you most having this problem? *

 
What have you already tried to do on your own to help/fix this problem? *

 
What kind of treatment have you already received for this specific problem? *


 
If you tried any of the above - what has helped? What worked and what didn't? *

 
What is the number one thing you aren't doing right now, but wish you could be doing, because of this problem? *

 

 If you could have this problem solved, what kind of value would that bring to your life right now? *

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