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THE NEUROSCULPTOR
SERVICES
FILL OUT THIS QUESTIONNAIRE & HELP ME ASSESS YOUR NEEDS
First Name
Last Name
Email
Would you consider your issue:
Acute (Indentified Single Issue)
Chronic (Longterm Complex State)
Would you describe your Symptoms as:
Trauma
Anxiety
Depression
Grief
Phobia
Other
How long have you been experiencing these symptoms?
Less than 1 year
1 - 5 years
6 - 10 Years
10 + Years
Are you aware of a specific experience or event which may have triggered your symptoms?
Yes
No
Perhaps
Are there other experiences in your past which may have impacted you emotionally?
Yes
No
Perhaps
What is your greatest fear in life?
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15 min
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Free Consultation
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Intensive Breakthrough Session
Trauma Healing Session
Anxiety Treatment Programme
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