Dare To Heal | Titilayo Ameh

Dare to Heal & Live In Control Biofeedback Session Pre Assessment

To make your experience go smoother kindly fill in the form below to get you started.

First name

Last name

Birthday

Day

Month

Year

Place of Birth / Time of Delivery (if known)

Email

Sex

Address:

Street

City

State / Province

Postal / ZIP Code

More about yourself

Marital Status

Phone

Please list any specific stressors you are currently experiencing:

Please list any specific health problems you are currently experiencing:

Please list any specific difficulties with your appetite or eating patterns:

Please list any specific sleep problems you are currently experiencing:

Please list any highs and lows in your relationship:

Please list specific stressors in your workplace, business, or home life:

What do you consider to be some of your challenges?

What do you consider to be some of your strengths?

Upload an Image of Yourself

Please share a mantra / affirmation/ intention / spiritual reference or just a word you would like the biofeedback machine to run during our consultation.

Dare to Heal & Live In Control Biofeedback Session Pre Assessment

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