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* 1. Your name

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* 2. In what city/ country do you reside? 

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* 3. Your approximate income:

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* 4. Tell us your story. What are you moving through, why are you seeking alternative care? If you are nominating a sister, please share her story here.

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* 5. Are you able to commit to your own healing (i.e. scheduling your appointments and getting to each of them on time; following through with life changes that may be recommended by your practitioner?)

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* 6. Your email address

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