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Congratulations on prioritizing You! Please complete and submit this form to request your free consultation.

Consultation Language

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First Name / Nombre

Last Name / Apellido

Email / Correo Electronico

Telephone / Telefono

Address / Direccion

City, State / Ciudad, Estado

Zip Code / Seguro Postal

Country / Pais

How did you hear about us? / Como nos consiguio?

Yes, subscribe me to your newsletter. / Subscribase

If "Other" please specify. / Si "Otra Cosa", especifique.

Have you ever been diagnosed with any of the following? Depression, Bipolar, OCD, ADHD, CPTSD, Epilepsy, Schizophrenia, DID or any other mental health issue? - ¿Ha sido diagnosticada(o) con alguna enfermedad mental?

Yes / Si

No

Are you currently taking a Rx and/or under the care of a medical or mental healthcare professional? - ¿Esta tomando medicamento actualmente o bajo el cuido de algun medico?

Yes / Si

No

Have you ever been hypnotized? / ¿Ha sido hipnotizada(o) anteriormente?

Yes / Si

No

Any other questions? - Cualquier otra pregunta?

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November 2025