Chinese Energetics Consultation Form

Fill out consultation form by clicking on each of the 4 steps.
Make sure you fill out as much information for each step so we can best assist you.

Fill out Step 1, THEN CLICK ON STEP 2 TAB

Fill out Step 2, THEN CLICK ON STEP 3 TAB

Fill out Step 3, THEN CLICK ON STEP 4 TAB

Fill out Step 4, THEN CLICK ON Submit Consultation Button

I. Personal Information

First Name:
Last Name:
Email:
Phone:
Profession:
Age:
Country:

Where did you find us?
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Go to Step 2

II. Physical Issues/Discomforts

Back Pain * Shoulder Pain * Headaches * Allergies * Aging * Beauty * etc..

1. List your physical discomforts?	2. How long have you had these discomforts?	3-a. What methods/practices have you tried before to improve these areas? (EFT, Yoga, Reiki, Acupuncture, etc..)	3-b. How much did these methods/practices help you previously with each area?
1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...
3-c. How long the pain relief last using the other methods/practices? Ex: Yoga helped relieve pain for 1-2 days but pain came back.	4. How many days per week and hours per day do you have this discomfort?	5. What is the minimum measurement/indicator of success or improvement for this condition? What is the minium result you would be happy with? Ex. 25%, 50%, 75%, %100 reduction is pain.	6. Describe loss of personal and professional productivity of a result of having these conditions.
1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...

7. What would your life look like professional and personally if we improve these conditions?

Go to Step 3

III. Emotional/Mental Issues

Smoking Cessation * Addictions * Public Speaking * Interpersonal skills * Social Dynamics *
Fears/Phobias * Claustrophobia * Fear of Flying * Anger & Depression * ADD-ADHD/OCD * Eating Disorders*
Weight Loss * Trauma & Abuse * Relationship Improvements * Couples & Singles

1. List your areas of distress?	2. How long have you had these areas of distress?	3-a. What have you tried before to improve these areas of distress (EFT, Yoga, Reiki, Acupuncture, etc..)?	3-b. How much did these methods/practices help you previously with each area?
1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...
3-c. How long did the other methods and practices help before the distress came back? Ex: Reiki helped relieved work stress immediately afterwards but I experience same stress buildup in daily business meetings.	4. How many days per week do you experience distress for each area? How many hours per day do you experience distress for each area?	5-a. How much personal and professional productivity did you lose as a result of experiencing distress?	5-b.Describe if you are experiencing any physical discomfort related to emotional and mental distress? Ex: Everytime I get overwhelmed at work, I get a bad headache.
1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	1) 2) 3) 4) List More...

6. What is your minimum indicator of success to measure improvement of your condition? What is the minimum improvement required for you to be happy? Ex. 25%, 50%, 75%, %100 reduction is pain.	7. Describe loss of personal and professional productivity of a result of having these conditions.	8. What would your life look like professional and personally if we improve these conditions?
1) 2) 3) 4) List More...	1) 2) 3) 4) List More...	a. What could you do more of Personally? Play Sports, Play w/ Kids, Travel, etc... b. What could you do more of Professionally? c. What could you have more of? Money, Love, Friendships, etc.. d. Who would the new you be? Better Mom/Dad, More Successful Business Person, etc..

Go to Step 4

IV. Other
What are your Interests?
	Seminars Chinese Energetics Intuitive Development - Foundations 1-day $250 * Chinese Energetics Intuitive Development - Intermediate 1-day $250 * Yuen Method Level I 2-day $500
	Private Coaching
	1-Session - $150/Session * 5-Session Package - $130/Session ($100 Savings) 10-Session Package - $120/Session ($300 Savings)
	Programs
	Basic program, 2-session + 1-day Seminar $500 ($50 Savings) Elite program, 2-day seminar + 7-session $1200 ($350 Savings)

	* Name Your Value. We try to provide financial assistance from time-to-time. Click Here to learn more.