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First name*

Last name*

Email*

Phone*

What condition do you suffer from?*

Have you been diagnosed?*

As best as you can, please describe your symptoms:*

How does this effect your life?*

Why is it important for you to change?*

How long have you had your condition?*

Are you on any medication? If so, please list

Have you tried any alternative therapies/approaches? If so, please list

Have you found anything that gives you relief? If so, please list

Please note how often you consume alcohol, if any

Can you commit to 2 sessions a week for 4 to 6 weeks without interruptions?*

Do the course prices, £240 for 4 weeks or £340 for 6 weeks work for you?*

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