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NAME*
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BEST EMAIL* (PLEASE USE THE SAME INFO AS YOU GAVE ON THE APPOINTMENT BOOKING)
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OBVIOUSLY, OVERCOMING THE SYMPTOMS AND ACHIEVING YOUR TRUE BADDASSERY TAKES A HELL OF A LOT OF WORK, GRIT AND DETERMINATION.*
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Neutral
Extremely Agree
Disagree
Agree somewhat
IN ONE WORD, DESCRIBE HOW YOU FEEL RIGHT NOW? *
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HOW WOULD YOU FEEL IF YOU DIDN'T HAVE THIS PROBLEM?*
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YOU ARE ALREADY GOOD ENOUGH. YOU ARE SMART ENOUGH. ARE YOU READY TO LIVE IN THE ESSENCE OF YOUR BEAUTY, AND THE FREEDOM OF A LIMITLESS UNINHIBITED LIFE?*
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I am 100% committed and will do whatever it takes.
I want my life back. but I am a little intimidated.
Avoid it at all costs as it is easier.
DO YOU PROMISE TO SHOW UP FOR YOUR SCHEDULED APPOINTMENT ON TIME and DISTRACTION FREE? PLEASE CONFIRM BY TYPING THIS SENTENCE IN THE BOX BELOW: "YES, I WILL" *
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