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Cortisol Treatment Intake Form
Personalized Wellness
Email
*
First name
*
Last name
*
Are you experiencing any pain, had a recent injury, or dealing with a particular problem/s?
*
How much stress are you experiencing on regular basis?
1 - lowest
2
3
4
5 - highest
Are you taking any medications?
If so, would you like to stop taking medications and heal your body with food and herbs?
Yes
No
Would you like to learn more about diet and nutrition? If so, what are your goals for your nourishment?
The cortisol treatment involves essential oils and a natural mask to cleanse and revitalize your body. Do you have any allergies that can be affected by the ingredients. Or, are there any scents you don't like ?
Do you have any questions regarding the treatment/s? What are your goals for stress relief and hoping to receive from the session/s?
Do you have any questions for me?
Submit
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