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Integration #1
1.
Full Name
2.
Email
3.
How many weeks have you been on our treatment protocol?
0
12
Clear
4.
What blend are you currently working with?
Elevate
Expansive
Balance
Golden Mind
Flow
Huachuma
Amanita
5.
How many capsules a day have you been taking?
1
2
3
Other (please specify)
6.
What was your initial intention for beginning our treatment protocol?
7.
Have you noticed a change in the relationship with your original intention? (check all that apply)
Nope
Slight change
Some change
A great deal of change
Change for the better
Change for the worse
8.
Are there any uncomfortable experiences that you've had that you'd like us to be aware of?
No
Yes
Please specify
9.
Are you feeling that there needs to be an adjustment to your current treatment protocol? If so, please describe your thoughts.
Nope
Yes
If yes, please specify:
10.
Please rate your overall experience thus far
Extremely valuable
Very valuable
Somewhat valuable
Not so valuable
Not at all valuable