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NISHKA SOMATICS
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Full name
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Email
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Birthday
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Day
Month
Month
Year
Are you currently receiving treatment or medication from a doctor or other practitioner?
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Yes
No
If yes, please give details
Briefly describe why are you seeking therapy and/or coaching with me?
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What would you say are your three immediate struggles?
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Anything else you feel relevant that could be part of why you are where you are today?
On a scale from 1-10 How committed are you to your personal change? (10 is 100% ready, 1 is not at all)
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Choose one
Are you financially ready to invest in a coaching program?
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Yes
No
Submit
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