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Free Assessment Form
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Free Assessment
Free Assessment Form
Name
*
Whatsapp Number
*
E-Mail
*
Date for consultation
*
Time for consultation
*
What aspect is your most concerning worry related to? *
*
Physical Aspect (Suffering=Pain)
Mental Aspect: (Suffering = inability to assert independence over situations, stemming from a lack of self or situational awareness and/or the inability to discern between right and wrong.)
Option 3Emotion Aspect (Suffering= discontentment from unfulfilled desired)
Energetic Aspect (Suffering= Breach in morality issues like values and faith)
No worries at all
Are multiple concerns stemming from different aspects troubling you simultaneously?
*
Yes
No
May Be
There is just one concern, or none at all.
Are multiple concerns stemming from the same aspect troubling you simultaneously?
*
Yes
No
May Be
There is just one concern, or none at all.
How intense have your worries been lately? *
*
High
Medium
Low
Not applicable
How does that effect your daily performance at work? *
*
Lack of focus
Lethargy
Discontentment
Other
Would you like us to reach out to you with holistic wellness solutions tailored to your submissions?
*
Yes
No
Any notes or queries for us?*